William Francis Galvin Secretary of the Commonwealth of Massachusetts Corporations Division th One Ashburton Place, 17 Floor Boston, MA 02108 617-727-9640 Foreign Corp. Fax Filing Coversheet FAX INFORMATION Number of Pages (not Fax To: 617-624-3891 including coversheet): Senders Name: Senders Fax Senders Telephone Number: Number: CREDIT CARD PAYMENT INFORMATION Credit Card Type MASTER CARD VISA (please circle one): Credit Card Number or Account Number Name on Credit Card: Billing Address for Credit Card (please include street, city, state and zip code): Telephone Number: ( ) ____ -_______ Security Indicator*: Expiration Month: Expiration Year: *The Security Indicator is required for payment by Visa credit card. On a Visa card, the security indicator is the non-embossed 3-digit number on the card signature panel found on the back of the card. In the signature panel, there is a large number (the account number) followed by a separate 3-digit number. You need the separate 3-digit number. There is an expedited service fee associated with fax filings. These fees cover the cost of the technical expertise necessary to provide the convenience of on-line and fax filing. You can obtain the expedited service fee associated with your filing by visiting our website at www.state.ma.us/sec/cor and clicking on the link expedited service fee.