Application To Register Securities Pursuant To OAR 441-065-0220 0230 {440-2013}

Oregon Department of Consumer & Business Services Division of Finance & Corporate Securities 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 (503) 378-4140 ! Fax: (503) 947-7862 ! TTY: (503) 378-4100 www.oregondfcs.org APPLICATION TO REGISTER SECURITIES Pursuant to OAR 441-065-0220, 0230 Check one: Initial Amendment Renewal of no.: Instructions: Use this form for registering offerings under OAR 441. Attach pages if space is insufficient. Offerings registered pursuant to OAR 441-065-0220 must submit the offering documen t. Offerings registered pursuant to OAR 441- 065-0230 do not require submission of documents unless requested by the Department of Consumer and Business Services. 1. Fees: 1/10 of 1 percent of the amount being offered in Oregon. Minimum fee, $200; maximum fee, $1,500. (Fees are not prorated or refun dable.) Registration fee: $ Number of issuer salespeople: x $50 = $ Total fees enclosed: $ 2. Issuer name by which offering is to be known: Name, address, and telephone number of issuer, or issuer to be formed, and principal offices, if any, in this state. (Where required, issuer must file appropriate name reservation or organizational documents before an order may be issued pursuant to this application.) Name: Phone: ( ) Address: City: State: ZIP: 3. Correspondent: Name, address, and telephone number of attorney or any other corresponde nt to whom communications regarding this application should be sent: Name: Phone: ( ) Address: City: State: ZIP: Continued on next page Visa MasterCard Make check or money order payable to Oregon Division of Finance and Corporate Securities. If paying by credit card, applicant must sign credit-card information box. Credit card number Expiration date Mail application with payment to: DCBS Fiscal Services Name of cardholder as shown on credit card P.O. Box 14610 Salem, OR 97309-0405 $ Cardholder signature Amount Fiscal use only: 62110/1008 4. Securities to be offered: Check one: 440-2013 (2/04/COM/WEB) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Application to register securities continued from previous page Common stock: $ Par value: $ Preferred stock: $ Units of limited partnership interest Other (please describe): a. Total offering Amount to be offered in Oregon Proposed offering price: $ Number of shares or units: Number of shares or units: Amount: $ Amount: $ b. Manner of payment Will deferred payments be allowed to purchasers? No Yes If yes, please provide details: c. Rescission of prior sales Does this offering involve rescission of any prior sales? No Yes If yes, please provide details: 5. Oregon and federal status: Set forth the specific provisions of Oregons Division 65 and the spe cific provisions of federal statutes and regulations under which this offering is to proceed : Oregon: Federal: 6. Other state transactions: a. List the other states in which these securities will be offered or in wh ich previous offers or sales have occurred and indicate whether the sales will be (or were) under state registrat ion or exemption: b. List the states, if any, that have refused, by order or otherwise, to au thorize sale of these securities or have revoked or suspended the right to sell these securities, or in which an application for registration has been withdrawn. Provide full details: 440-2013 (2/04/COM/WEB) Page 2 of 7 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Application to register securities continued from previous page 7. Broker-dealer or salespersons: Name, address, and telephone number of the broker-dealer licensed in Ore gon and lead broker-dealer, if any. Name: Phone: ( ) Address: City: State: ZIP: Is this broker-dealer a member of NASD? Yes No If licensing a salesperson to the issuer in lieu of using a broker-deale r or employing a salesperson who is already licensed in Oregon, list the salespersons name, address, Social Secu rity number and CRD number, if applicable. If licensing a salesperson to the issuer, Form U-4 and $50 fee must be s ubmitted with this application. If claiming an exclusion from licensing under OAR 441-175-0040, so indicate. Name: Phone: ( ) Address: SSN: City: State: ZIP: CRD no.: Claiming exclusion from licensing under OAR 441-175-0040? Yes No Form U-4 and $50 fee enclosed? Yes No Note: An order of registration will be issued only when licensing of the issuer salespersons, if required, is completed.8. Professionals involved: Provide the names, addresses, and telephone numbers of all professionals who have rendered service or have given advice in connection with this offering if they ar e named as experts in your sales literature or presentations or whose names are used to give authority to statements ma de concerning this offering. Describe their scope of activities. Include attorneys, accountants, appraisers, enginee rs, etc. Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: 440-2013 (2/04/COM/WEB) Page 3 of 7 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4Application to register securities continued from previous page 8. Professionals involved (continued; see Page 3 for instructions) Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: Name: Phone: ( ) Address: City: State: ZIP: Attorney Accountant Appraiser Engineer Other (specify): Scope of activities: 440-2013 (2/04/COM/WEB) Page 4 of 7 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 5Application to register securities continued from previous page 9. Business plan: Describe the nature of the business to be con