Common use of NASD AFFILIATION Clause in Contracts

NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): Yes _________ No __________ If Yes, please describe: _________________________________________________________ _________________________________________________________ _________________________________________________________ *If Subscriber is a registered representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by Article III, Sections 28(a) and (b) of the Rules of Fair Practice. _________________________________ Name of NASD Member Firm By: ______________________________ Authorized Officer Date: ____________________________ Part V REGISTRATION QUESTIONNAIRE The following questions in this Part V are specifically intended to provide information to the Company for the Company's use in the preparation of the Registration Statement contemplated by the Subscription Agreement and for specific inclusion in such Registration Statement.

NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): Yes _________ No __________ If Yes, please describe: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ *If Subscriber is a registered representative Registered Representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by Article III3, Sections 28(a) and (b) of the Rules of Fair Practice. _________________________________ Name of NASD Member Firm By: ______________________________ Authorized Officer Date: ____________________________ Part V REGISTRATION QUESTIONNAIRE The following questions in this Part V are specifically intended to provide information undersigned is informed of the significance to the Company for the Company's use in the preparation of the Registration Statement contemplated by foregoing representations and answers contained in this Confidential Investor Questionnaire contained herein and such answers have been provided under the Subscription Agreement and for specific inclusion in such Registration Statement.assumption that the Company will rely on them. Date: ______________________ By: ____________________________________ Printed Name:__________________________________