Fill and Sign the Private Sale Purchase Form

Investment Letter for a Private Sale of Securities To:The Board of Directors of ______________________ (Name of Issuer of Securities) ____________________________________ (Street Address of Post Office Number) ____________________________________ (City, State and Zip Code) Ladies and Gentlemen: In connection with my purchase of _______ shares of the $__________ par value of common stock of ______________________ (Name of Corporation) , I represent to you that I am acquiring such shares for investment for my own account and not with a view to resell or otherwise transfer such shares, and that I do not intend to resell or otherwise dispose of all or any part of such shares unless and until I determine at some future date that changed circumstances, not now being contemplated, make such disposition advisable. In such event, I will subsequently register my securities under the Securities Act of 1933 unless an exemption from such registration is available. Before re-sales are made, an opinion of counsel satisfactory to the corporation, or a no-action letter, will be furnished stating that the sale may be made without violating the Securities Act. I confirm my understanding and agreement that _______________________ (Name of Corporation) is selling its capital stock to me under the Securities Act of 1933 in reliance on the foregoing representation and agreement. Witness my signature this __________________ (date) . _________________________ (Printed Name of Investor) _________________________ (Signature of Investor)