Midwest Regional Review Program Application

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Midwest Regional Review Application

1. Name of Issuer:______________________________________________________
   
   Fax Number:______________________E-Mail Address:______________________
   
   
   
2. The issuer ("applicant") is filing for Coordinated Midwest Regional Review in the following states (please check all that apply; at least two must be checked):
   

   ___ Illinois	___ Indiana	___ Iowa*	___ Kansas	___ Michigan
   ___ Missouri	___ Nebraska	___ North Dakota	___ South Dakota	___ Wisconsin

   * Offering may not exceed $1 million
   
   
   

3. The applicant shall send to each state, a copy of this Application, accompanied by the exhibits (See Appendix A) and the fees required by that state (see Appendix B). These filings shall be made simultaneously in each state as checked in Item 2 above. The documents filed in each state shall be identical. (Note:  Subsequent to the initial filing for Midwest Regional Review, the applicant may file a new application in at least two of the remaining participating states, but will then be subject to a new coordinated review.)
   
   Type of filing (please check one):
   
   _____ Small Company Offering Registration (SCOR Form U-7)
   
   _____ Question/Answer Form Model A under Regulation A
   
   _____ Offering Circular Model B under Regulation A Form 1-A (Traditional Disclosure)
   
   
   
4. Undertakings of Applicant:
   
   The applicant agrees that it will file simultaneously in each state checked above.
   
   The applicant waives automatic effectiveness in each state checked above.
   
   The applicant agrees to resolve outstanding comments through the lead state and agrees to provide the lead state with a copy of the amended offering document marked to show changes.  (Note:  State-specific comments must be resolved with the state to which the comment applies.)
   
   The applicant understands that the securities to be registered must be sold by an agent that is either registered or exempt from registration in the subject state. The applicant agrees not to allow sales by agents that have not been registered or are not exempt in the state in which they are selling.
   
   
   

Applicant Representative:

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Signature & Date

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Print Name & Title