New England Regional Review Application Form {NERRAF}

NEW ENGLAND REGIONAL REVIEW APPLICATION FORM Name of Company 1. States in which the company intends to file for purposes of regional review: Please check applicable boxes. Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont 2. Type of filing: Please check Small Corporate Offering Registration Regulation A as filed with the Securities and Exchange Commission on the Question and Answer Form Model A. I request that my filing in the states indicated above be processed as a regional review filing. I waive automatic effectiveness in the above named states. I attest that all filings and amendments will be identical in each of the states identified above. I understand that the securities to be registered must be sold by an agent that is either registered or exempt from registration. I agree not to allow sales by agents that have not been registered or are not exempt in the state in which they are selling. Chief Executive Officer Print Print ________________________ Name American LegalNet, Inc. www.FormsWorkFlow.com