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STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 10-2-1

Application for Registration by Qualification

1. Name of Issuer

Street Address, City & State, Zip Code

Telephone Number

2. Name of Applicant

Street Address, City & State, Zip Code

Telephone Number

3. Name of Correspondent

Street Address, City & State, Zip Code

Telephone Number

4. Agent or Underwriter

Street Address, City & State, Zip Code

Telephone Number

5. Transfer Agent

Street Address, City & State, Zip Code

Telephone Number

6. Description of Securities to be offered in Utah

Number of Shares or Units to be offered

Class

Proposed Offering Price per Share or UnitAmount in Dollars

7. a. List the states, other than Utah, in which the issuer or applicant proposes to offer the securities for sale to the public:b. List the states in which the securities are eligible for sale to the public:

8. Maximum Commission to be paid

9. List name and residential address of all directors or officers or partners of the issuer or individuals who own of record beneficially 10% or more of the outstanding shares of any class of equity securities of the issuer: NameAddress

10. Escrow Agent (Include Name of Financial Institution)
Escrow period

11. The issuer's fiscal year end

12. Are there (or have there been) any criminal or civil complaints, or investigations by the SEC, NASD, or other State Securities Department, covering the company or any of its officers?

Yes_____ No_____ If answer is yes, explain:

13. The applicant hereby applies for registration of securities under Section 61-1-10 of the Utah Uniform Securities Act and in consideration thereof agrees:

(a) After either the close of the offering or the expiration of effectiveness of the registration statement, whichever occurs first, applicant shall file within 10 business days of a request of the Division, a list of purchasers in the offering, the residential address of each purchaser, the amount of securities purchased and the consideration paid by each purchaser;

(b)All amendments to the prospectus will be promptly filed with the Division, distributed to purchasers in the offering, and made a part of any prospectus used thereafter;

(c)The Division, market makers and security holders will be promptly notified in writing of any change in the management, purpose, and control of the issuer, or any material or adverse condition affecting the issuer, so long as the registration statement is effective;

(d)Financial statements will be submitted to the Division in accordance with paragraph H. of R164-10-2.

14. The applicant hereby affirms that no material contract, understanding or agreement exists which is not reflected in the registration statement.

State of _____________________)
County of ___________________)

The undersigned,____________________ , being first duly sworn, deposes and says that he has executed the foregoing application for and on behalf of the applicant, that he is the ______________ of ________________ such applicant and is fully authorized to execute and file such application; that he is familiar with such application; and that to the best of his knowledge, information and belief, the statements made in such application are true and the documents submitted herewith are true copies of the original thereof.

____________________________
Signature
Subscribed and sworn to before me this_____ day of__________ , 19____

Notary Public________________________

My Commission Expires_______________________

The undersigned directors, officers, partner or partners of the issuer named herein do hereby affirm that they have read this registration statement and all exhibits thereto, and that the contents thereof are true to the best of their knowledge and belief; and further that (correspondent) _________________ is hereby authorized to execute this registration statement on behalf of the issuer, and continuing authority is hereby delegated to him to file any amendments, supplementary or periodic information thereto as may be applicable or required, pursuant to the Utah Uniform Securities Act, and rules promulgated thereunder.

SignatureTitle

__________________________ ____________________________________

__________________________ ____________________________________