Application For License For New Hampshire Issuer-Dealer {D-1}

Form D-1 State of New Hampshire Department of State Bureau of Securities Regulation No. Rec'd App'd Fee Granted Application for License for New Hampshire Issuer-Dealer The undersigned hereby applies for a license authorizing it to sell its securities in this state under the New Hampshire Blue Sky Law and makes the following statement: 1. Name of applicant 2. Address of applicant 3. Telephone No. 4. Date of incorporation or organization, and place: 5. Type of Organization: Corporation Partnership/LLP Yes LLC Proprietorship Other 6. Are you actually engaged in business in this state? 7. Give the names, residences, business addresses, capacity and title of all persons interested in the business as principals, officers, directors, managers or managing agents. Name Residence Business Address Capacity and Title 8. In what other states have you ever applied for a securities license? 9. In what other state are you licensed or registered? 10. State briefly the general plan and character of the business of applicant, specifying the nature of property in which it is proposed to deal, and the method of transacting business, whether by solicitation, advertisement, correspondence or otherwise. 11. Type and amount of securities for which qualification is requested 12. Date and month of end of fiscal year American LegalNet, Inc. www.FormsWorkflow.com There are attached hereto and made a part hereof: (a) Copy of charter, articles of incorporation, or limited liability company, or limited partnership agreement certified by proper state official. (b) Copy of by-laws certified by Clerk of the Corporation. (c) Certified copies of Profit and Loss Statement and Balance Sheet as of last December 31, or close of fiscal year. (d) Pro-forma Balance Sheet (if new entity with no operating history). (e) Copy of offering memorandum or prospectus. (f) Three references as to the business repute and character of applicant, from unaffiliated persons, including names, addresses, and telephone numbers. (g) Form D-1, properly executed, by each of the persons signing below. (h) There is enclosed herewith the fee due on filing this application. (Corporate seal if incorporated) THIS APPLICATION MUST BE SIGNED BY ALL THE OFFICERS, PRINCIPALS, DIRECTORS, MANAGERS, MANAGING AGENTS, OR PARTNERS OF THE CORPORATION OR OTHER LEGAL ENTITY. 1. Signature Date 4. Signature Date DOB SS# DOB SS# 2. Signature Date 5. Signature Date DOB SS# DOB SS# 3. Signature Date 6. Signature Date DOB SS# DOB SS# STATE OF COUNTY OF Subscribed and sworn to before me this _______ day of ________________, ______ Notary Public My commission expires Sec. Form D-1 9/2008 American LegalNet, Inc. www.FormsWorkflow.com