Application For Retroactive Qualification Of Securities Sold Without Compliance {39}

Form 39 File Number Application for Qualification of Securities Previously Sold in Ohio Without Compliance With Section 1707.01 to 1707.45, Inclusive, Revised Code of Ohio (Section 1707.39, Revised Code) Registrant Must Not Complete . DIVISIO N RECORD ONLY Date Checked By Notation Filing Fee ($100.00) Received Qualification Fee Received Record Made Division Order (Application Refused/Granted) Examination Requested Prior Registration (Registrant Mus t Not Fill In ) . (Section) (File) (Date) (Amount) ( Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description ) (Price) This Registration (Registrant Must Not Fill In ) . (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) 1. Issuer's Name 2. Issuer's Address 3. The issuer is: ( State whether individual, partnership, corporation, syndicate, association, etc.) 4. Date of incorporation or organization under the laws of ( State ) 5. The charter or articles of association of the issuer now authorize the following securitie s: Amount Description Division of Securities 77 South High Street 22 nd Floor Columbus, Ohio 43215 COM 4510 4/11 /19 An Equal Opportunity Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 39 6. The issuer now has the following securities sold or subscribed: (Include all classes of stock, bon ds, debentures, promissory notes, or other securities.) Amount Description Amount Description 7. The Securities now sought to be qualified, which have been sold or subscribed in OHIO without compliance with Section 1707.01 to 1707.45, inclusive R.C., are: A. Type of security to be qualified: (e.g. common stock, limited partnership units, etc.) B. Sales Price: (if there were differing prices, attach a separate sheet listing date of sale, number of units, and sales price for each sal e.) C. Earliest Date of Sale: (List the earliest date at which (i) a subscription agreement was signed by any purchaser of securities to qualified or (ii) the date at which the purchaser tendered funds or things of value for the securities to be qua lified.) D. Latest Date of Sale: (List the latest date at which (i) either a subscription agreement was signed by any purchaser of securities to be qualified or (ii) the date at which the purchaser tendered funds or things of value for the securitie s to be qualified.) E. Amount of Securities to be qualified in units. 8. The following are the names and business addresses of all directors, officers, promoters, trustees, partners, or other managers of the issuer: Name Business Address City St ate Zip 9. Identify who sold the securities. If other than the issuer, indicate name, address, and Ohio broker - dealer salesman number for all concerned. Name Business Address City State Zip 10. Indicate amount of commission (dollar amou nt and percentage) or other remuneration paid to all individuals connected with this sale: 11. Submitted herewith is: (Total fees) (Check No.) (Needed in case of refund of Qualification Fee) Two fees are r equired as follows: Filing Fee ................................ ................... $100.00 Qualification Fee (minimum) ....................... $100.00 (1/5 of 1% of the aggregate price; up to a minimum fee of $2,000.00) 12. Attached hereto and made part hereof are the following exhibits: A. A receipted copy of the - Laws, and Regulations, if the issuer is a corporation, or a copy of instruments governing the operation of the issuer and rights of participants if the issuer is a partnership, trust, syndicate or a ssociation. American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce Form 39 B. A schedule showing (1) preferred stock, etc.) held by each director, promoter, trustee, partner, or other executive manager or officer (2) a detailed description of what was paid to the issue r in cash, real estate, patents, services or other items of value in the purchase of such securities by each of such persons. C. A schedule showing (1) the names and addresses of all persons who purchased securities sold in violation of Section 1707. 01 to 1707.45, inclusive, R.C., now sought to be qualified, and (2) a detailed description of what was paid to the issuer in cash, real estate, patents, services or other items of value in the purchase of such security by each of such person. D. A co py of each subscription agreement signed by the purchasers. E. with such sale. F. Copies of any letters, literature, or prospectus G. Provide balance sheet and income statements for the prior three years for the entity whose securities are to be qualified. Supply either: (1) etter, or (2) An affidavit of the Chief Executive Officer of the entity whose securities are to be qualified hereunder. Affidavit shall be made under oath or affirmation of the officer attesting that, to his best knowledge and belief, the financial state ment and supporting schedules are true and correct. (Name of Issuer or Applicant) X Signed By: (Officer, Partner, Dealer or Applicant) COUNTY OF STATE OF being first duly sworn, deposes and says that he is t hat he (Officer, Partner, Dealer or Applicant) has read the foregoing applications; that he has knowledge of t he facts, and that the facts stated are true, as he verily believes. X Signed By: (Officer, Partner, Dealer or Applicant) Sworn to and subscribed before me this day of (Month, Year) Notary Public County Nam e, address, and telephone number or correspondence to whom communications regarding this application may be sent: The Statement of Non - Prejudice to be signed by the original purchasers will be forwarded upon receipt of this application with appropriate fees attached. Address all communications and make all checks payable to: Ohio Division of Securities, 77 South High Street, Columbus, Ohio 43215 - 6131 614 - 644 - 7381 COM 4510 4/11 /19 American LegalNet, Inc. www.FormsWorkFlow.com