Legal Annual Registration Form

LEGAL ANNUAL REGISTRATION FORM

This Annual Registration Form is made effective as of Day: Month: Year: , by and between Registrant Name: (the "Registrant") and Registry Operator Name: (the "Operator").

RECITALS

WHEREAS, the Registrant is duly organized and in good standing under the laws of the jurisdiction set forth below and is required to file an annual registration statement concerning its organization, status and designated contacts; and

WHEREAS, the Operator provides administrative registry services and maintains records on behalf of entities filing annual registrations and has agreed to accept the Registrant's submission and to retain a copy of the Registrant's annual information; and

WHEREAS, the Registrant desires to submit the required information and to certify the accuracy of such information to the Operator in accordance with the terms set forth herein.

NOW, THEREFORE, in consideration of the mutual covenants contained in this Form and for other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. REGISTRATION DATA

1.1 Registrant Legal Name: .

1.2 Registration Number (if assigned): . Jurisdiction of Organization: .

2. ENTITY TYPE

Indicate type of entity (check all that apply): Corporation Limited Liability Company Partnership Other If Other, describe:

3. DESIGNATED REGISTERED AGENT

3.1 Designated Registered Agent Name: .

3.2 Agent Type: Individual Organization

3.3 Consent of Registered Agent: By checking the box below, the designated agent acknowledges and accepts appointment as registered agent for service of process for the Registrant. Agent consents to appointment

4. ANNUAL CERTIFICATION

4.1 The Registrant hereby certifies, under penalty of law, that the information provided in this Annual Registration Form is true, correct and complete as of the effective date set forth above, and that the person executing this Form on behalf of the Registrant is duly authorized to do so.

4.2 Registrant agrees to notify the Operator in writing within thirty (30) days of any change to the information provided herein and to provide corrected documentation as may be reasonably requested by the Operator to maintain registry records.

5. REPRESENTATIONS AND WARRANTIES

The Registrant represents and warrants that (a) it is duly formed and in good standing under the laws of the jurisdiction identified above, (b) the person signing below is authorized to bind the Registrant, and (c) the information submitted does not violate any contractual commitment or legal obligation applicable to the Registrant.

6. RECORDS, ACCESS AND FEES

6.1 The Operator shall retain records of this Annual Registration Form in accordance with its standard records retention practice and shall permit the Registrant to inspect or obtain copies of its registration record upon reasonable request.

6.2 Fees: Registrant shall remit the fee required for processing this annual registration. Fee amount: Payment method: .

7. CHANGES, AMENDMENTS AND WAIVER

This Form may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right, nor shall any single or partial exercise preclude any other exercise of such right.

8. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth below (or such other address as either party may designate by written notice). Notice is effective upon receipt.

9. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by and construed in accordance with the laws of the jurisdiction of: , without regard to conflict of laws principles.

If any provision of this Form is held to be invalid, illegal or unenforceable in any respect, the remaining provisions shall continue in full force and effect. This Form, including all information and schedules delivered in connection herewith, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings.

10. COUNTERPARTS AND EXECUTION

This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures delivered by electronic means shall be valid and sufficient for all purposes.

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