Application To Register Securities {CT3}

Form U-1 or CT-3 APPLICATION TO REGISTER SECURITIES Application to the Department of Banking of the State of Connecticut pur suant to The Connecticut Uniform Securities Act. For Filing By: (check one) Coordination - Section 36b-17 Qualification - Section 36b-18 1. Name and address of Issuer: Principal office in this State: 2. Name, address and telephone number of correspondent to whom notices and communications regarding this application may be sent: 3. Name and address of applicant: 4. Registration or acceptance for filing is sought for the following de scribed securities in the amounts indicated: Offering Price Total Offering Offering in this state Description of or Proposed No. of Shares No. of Shares Securities Offering Price or units Amount or units Amount $ $ Totals $ $ Indicate the maximum commission to be charged: % 5. Amount of filing fee which is enclosed: $ (One-tenth of one percent of the maximum aggregate offering amount in C onnecticut: Minimum $300.00/Maximum $1500.00) 6. A Registration Statement (was filed) (is expected to be filed) w ith the Securities and Exchange Commission on and is expected to become effective on or about (date) . (date) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 27. (a) List the states in which it is proposed to offer the securitie s for sale to the public: (b) List the states, if any, in which the securities are eligible for sale to the public. (c) List the states, if any, which have refused, by order or otherwise , to authorize sale of securities to the public, or have revoked or suspended the right to sell the securities, o r in which an application has been withdrawn. 8. Submitted herewith as a part of this application are the following d ocuments (documents on file may be incorporated by reference): (a) One copy of the Registration Statement and (3) copies of Prosp ectus in the latest form on file under the Securities Act of 1933. (b) Agreement Among Underwriters, Underwriting Agreement, and Select ed Dealers Agreement. (c) Indenture. (d) Issuers charter or articles of incorporation as amended to date . (e) Issuers by-laws as amended to date. (f) Signed copy of opinion of counsel filed with Registration Statem ent pursuant to the Securities Act of 1933. (g) Specimen (type of security). (h) Consent to Service of Process accompanied by the appropriate corp orate resolution. (i) If an earning computation or similar requirement is required to be met in this state, attach a separate sheet as an exhibit showing compliance. (j) One copy of all advertising matter to be used in connection with the offering. (k) Others (list each): 9. The applicant hereby applies for registration or acceptance for fili ng of the above registered securities under the law cited above and in consideration thereof agrees so long as the r egistration remains in effect that it will: (a) Advise the above named state authority of any change prior to re gistration in this state in any of the information contained herein or in any of the documents submitted with o r as a part of this application. (b) File with the above named state authority within two business da ys after filing with the Securities and Exchange Commission (i) any amendments other than delaying amendments to the federal registration statement, designating the changed, revised or added material or informa tion by underlining the same; and (ii) the final prospectus, or any further amendments or supplements th ereto. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 (c) Notify the above named state authority within two business days ( i) upon the receipt of any stop order, denial, order to show cause, suspension or revocation order, injunction or restraining order, or similar order entered or issued by any state or other regulatory authority or by any c ourt, concerning the securities covered by this application or other securities of the issuer currently being offered to the public; and (ii) upon the receipt of any notice of effectiveness of said registration by the S ecurities and Exchange Commission. (d) Notify the above named state authority at least two business days prior to the effectiveness of said registration with the Securities and Exchange Commission of (i) any re quest by the issuer or applicant to any other state or regulatory authority for permission to withdraw any appli cation to register securities described herein; and (ii) a list of all states in which applications have been filed where the issuer or applicant has received notice from the state authority that the application does not c omply with state requirements and cannot or does not intend to comply with such requirements. (e) Furnish promptly all such additional information and documents in respect to the issuer or the securities covered by this application as may be requested by the above named state authority prior to registration or acceptance for filing. Date: Name of Applicant By (Name and Title) State of ) ) ) ss ) County of ) The undersigned, , being first duly sworn, deposes and says: That he has executed the foregoing application for and on behalf of the applicant named therein; that he is the of such applicant and is fully authorized to execute and file suchapplication; that he is familiar with such application; and that to the best of his knowledge, information and beliefthe statements made in such application are true and the documents submi tted therewith are true copies of theoriginals thereof. Name Subscribed and sworn to before me this day of , 20 . NOTARY PUBLIC My Commission Expires: (Notarial Seal) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 FOR AN ACKNOWLEDGMENT OF THE FILING OF THIS APPLICATION COMPLETE THE LEFT COLUMN BELOW Name and address of correspondent State of File Number Applicant Date Examiner Issuer Telephone Name of any broker-dealer or agent of issuer registered to do business u nder this chapter who may offer thesecurities in this state: American LegalNet, Inc. www.USCourtForms.com