Application For Registration By Qualification {RQ}

FORM RQ Colorado Division of Securities Colorado File No.: RQ________________ 1580 Lincoln Street, Suite 420 Denver, CO 80203 APPLICATION FOR REGISTRATION BY QUALIFICATION Pursuant to the requirements of section 11-51-304, C.R.S., application is made for registration of the described securities and the following information is submitted: 1. NAME AND ADDRESS OF ISSUER: 2. TITLE OR DESCRI PTION OF SECURIT Y: 3. AMOUNT TO BE REGISTERED: Offering Price Amount of Securities T otal Amount $ $ 4 Is this an initial Colorado registration or an amendment to increase the size of a previously registered Colorado offering? IA LIAITNNTMEDENM 5. NAM AND ADDRESSE OF PRINCIPAL BROKER-DEALER (IF ANY): 6. Will these securities be sold by an individual acting as a sales representative for the issuer? YES NO 7. NAME, ADDRESS AND TELEPHONE NUMBER OF ATTORNEY, AGENT OR CORRESPONDENT: 8. Attach Appointment and Consent to Service of Process (Forms U-2 & U-2a); or, if such forms have previously been filed with this office, state the date filed and the documents which they accompanied. 9. FILING FEE: $ (payable to Colorado State Treasu rer) ________________________________________________ Signature of Applicant Type the Name and Title of Applicant (Rev. 11/2002 ) www.FormsWorkflow.com