State of Washington Business Licensing Service PO Box 9034 Olympia, WA 98507-9034 1-800-451-7985 Corporate Information Must be filed with a Business License Application (or upon request) Type of license(s) requested. Check all that apply: Liquor Lottery A Corporation information Corporations must be registered with the Washington Secretary of State Name of corporation Corporation mailing address Street or route, city, state, zip code UBI number If known Date of incorporation State of incorporation Telephone number ( ) B Corporate officers Title Name Address/telephone number Date of birth Social security number C Stock information 1) Total amount of stock authorized to the corporation 2) Total number of shares issued or pending issuance D Stockholders List all stock issued or pending so we can determine each person's interest in the business. Name Address/telephone number No. of shares % of shares (state "pending" if not yet issued) Date issued Please attach additional sheets if necessary, in same format. The total "No. of shares" must equal the amount shown in Box 2 of Section C above. The total of "% of shares" must equal 100% Totals 100% E Certification I certify (or declare), under penalty of perjury under the laws of the State of Washington, that the information provided on this form and all attached documents is true and correct. Printed name of corporate officer Signature of corporate officer Title Date signed X American LegalNet, Inc. www.FormsWorkFlow.com For assistance or to request this document in an alternate format, please visit http://bls.dor.wa.gov/BLS or call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. BLS-700-311 (9/2/15)