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Thank You for your selection of My Transfer Agent, LLC . We appreciate the opportunity to service your company as Transfer Agent and Registrar. As a registered SEC Transfer Agent we are obligated to keep your shareholder information secure and private. We will NOT disclose non-public personal information about our clients and their shareholders to unrelated parties. We will ONLY provide information to our clients, their shareholders, (for their own account), or our clients' designated representative(s). Please refer to our Privacy Policy.

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* Indicates required fields.   STEP 1: Corporate Information Company Name: * Address: * City: * State/Province: * Zip/Postal Code: * Country: United States * Phone: * Fax: Company Email: (Your company's public email address) Person Completing Form (You): * Your Email: * Company Website: Public Company: yes no Traded on: -Select- Not Traded Pink Sheets Over the Counter NASDAQ American Stock Exchange * Symbol: State of Incorporation: -Select-ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVIVAWAWVWIWY* Overnight Acct: -Select- Fedex Airborne UPS DHL   Number:

STEP 2: Corporate Officers   Name Email CEO: * Email: * President: * Email: * Corporate Secretary: * Email: * Email: Email: Email:

STEP 3: Legal Counsel Legal Counsel: Address: City: State:   Zip: Phone: Fax: Email: Authorization: legal counsel is authorized to issue instructions on behalf of the company?

STEP 4: Authority for Email These contacts are authorized to issue and register new stock certificates on behalf of the company. Contact 1: * Email: * Contact 2: Email: Contact 3: Email:

STEP 5: Issues CUSIP # CLASS PAR VALUE PER SHARE SHARES AUTHORIZED SHARES ISSUED & OUTSTANDING SHARES AUTHORIZED BUT UNISSUED Common Warrant Preferred Bond $ Common Warrant Preferred Bond $ Common Warrant Preferred Bond $ Common Warrant Preferred Bond $ Common Warrant Preferred Bond $ Is there additional information regarding the shares which we will act as agent for (Prior Names, Splits or issues)? Are there any shares issued in the name of the company?   Yes No