Application For Registration Of Securities By Qualification {S-1}

Dishonored Check Fee - $15 + Interest State of Hawaii Department of Commerce and Consumer Affairs BUSINESS REGISTRATION DIVISION 335 Merchant Street, Room 203, Honolulu, Hawaii 96813 (808) 586-2722 APPLICATION FOR REGISTRATION OF SECURITIES BY QUALIFICATION 1. Name and address of issuer. 2. Address of issuer's principal office in the State, if any. 3. Amount of offering. A. Title and amount of each class of securities being offered in the State and elsewhere. B. Offering in the State. OFFERING PRICE Per Unit Aggregate $ $ $ $ UNDERWRITING DISCOUNTS AND COMMISSIONS $ $ NET PROCEEDS TO ISSUER C. 4. Registration fee in the State. (1/10 of 1% of the aggregate offering price of the securities to be sold in the State. Minimum $250; maximum $2,500) Name of dealer or dealers and their business address who will sell the securities in the State. (OVER) S-1 Rev. 03/04 B37 (Fee) American LegalNet, Inc. www.FormsWorkflow.com 5. If a registration statement as to the securities has been filed under the Securities Act of 1933, state the effective date of registration statement, if effective, and state whether any stop order has been made with respect thereto pursuant to said Securities Act of 1933, or whether any notice of intent to issue a stop order has been given, or, to the best knowledge of the applicant, is threatened. 6. The states, territories or other jurisdiction, if any, which have refused by order or otherwise to authorize the sale of the securities to the public, or have revoked or suspended the right to sell the securities, or in which any proceeding for the revocation or suspension of such right is pending, or in which an application for qualification has been withdrawn. 7. There shall be submitted a copy of the following: A. The issuer's charter or articles of association or other instrument of organization, together with all amendments thereto, certified by the officer of the state of the issuer's incorporation or organization having custody thereof, if not already on file in the Office of the Commissioner. The issuer's by-laws, together with all amendments thereto, certified by the secretary or any other duly authorized officer of the issuer. The indenture, if any, and all supplements thereto, under which the securities are to be issued. B. C. D. The basic underwriting agreement, if any, and any agreement or agreements among underwriters and dealers pertaining to the distribution of the securities within the State. E. F. An opinion or opinions of counsel as to the legality and validity of the securities and their issuance. A specimen copy of each certificate to be registered. G. A copy of all advertising material to be used in this State in connection with the offering and sale of securities. (Note: Any of the foregoing documents, A to G, may be submitted in preliminary form, clearly marked as such, in which case a definitive copy of each shall be filed promptly after execution, adoption or filing, as the case may be.) H. Prospectus - See attachment to this application for information required in the prospectus. Also refer to the Rules and Regulations under the Uniform Securities Act. 8. If the issuer is not domiciled in the State, there shall be filed the irrevocable written consent to service of process on the Commissioner as provided by Section 485-12, Hawaii Revised Statutes, together with a certified copy of the resolution of the board of directors, trustees, etc. authorizing the officers to execute the same. -2American LegalNet, Inc. www.FormsWorkflow.com 9. In connection with the offering, the issuer or dealer hereunder named hereby undertakes and agrees to file with the Commissioner all subsequent financial reports to be issued and all subsequent advertising literature to be used in the State. this day of , 20 . Dated at (Name of Applicant) } ss. By Title being first duly sworn on oath deposes and says that he/she is the of the applicant named in the foregoing application; that he/she is authorized to make this verification for and on behalf of said ; that he/she has read the application and all the exhibits, statements and documents attached thereto; that the information contained in the application, exhibits, statements and documents is true to the best of his/her information, knowledge and belief. (Signature of Applicant) Subscribed and sworn to before me this day of Notary Public, State of My commission expires: (Note: Registration under this section shall be effective for a period of one year and may be renewed for additional periods of one year by filing, by a date not later than 15 days prior to expiration of registration, a prospectus meeting the requirements provided herein and containing information as of a date not more than 90 days prior to the date of filing, together with the payment of a renewal fee of $20.) , 20 . (NOTARIAL SEAL) -3American LegalNet, Inc. www.FormsWorkflow.com