Issuer-Dealer Notice Filing Application {D-4}

STATE OF NEW HAMPSHIRE DEPARTMENT OF STATE BUREAU OF SECURITIES REGULATION Form D-4 No. Recd Appd Fee Granted Issuer-Dealer Notice Filing Application 1. Name of Issuer . (give full name) 2. Business Address . (Street and Number or PO Box) (Town) (Zip) 3. State of Formation . 4. Description of Securities Sold . (Include price per unit, type, and aggregate value) 5. Date of first sale . 6. Name or names of the representative or representatives of the issuer who are engaged in the sale of the securities . 7. Indicate whether any such agent has been convicted of a felony and include the date and place of the conviction . No license will be issued until all blanks in this form are properly filled out. The application shall be signed by that person or persons who are authorized to do so by the issuers board of directors or other governing body. Signed Dated Notarized: STATE OF COUNTY OF Subscribed and sworn to me before this day of , Notary Public Date of Expiration