Application for Consent to Transfer Securities Pursuant to Section

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STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

APPLICATION FOR CONSENT TO TRANSFER SECURITIES PURSUANT TO

SECTION 25151 OF THE CORPORATE SECURITIES LAW OF 1968

DFPI–260.151(a) (Register 2009, No. 39) (Rev. 11-20)

(Department of

Financial Protection

and

Innovation Use Only)

Fee Paid $______________________

Receipt

No. _____________________

Department of Financial Protection and

Innovation File No.___________________________

(Insert file no. of previous filings

before the Dept. if any)

FEE: $

(To be completed by applicant. The

required fee is $20 per transfer (Sec.

25608(m), Corp. Code).)

Date of Application: _________________

This represents (check appropriate box):

The initial filings. An amendment to application dated ________________________

THE SECURITIES PROPOSED TO BE TRANSFERRED ARE SUBJECT TO (CHECK

APPROPRIATE BOX)

LEGEND CONDITION. ESCROW CONDITION.

1. (a) Name of Issuer: ________________________________________________

(b) Former Name, If Any:____________________________________________

2. Description of securities proposed to be transferred: (State title of each class of securities

(e.g., Class A Common Stock). If rights, warrants and options are listed, also specify the

securities to be transferred upon exercise thereof. If securities are to be pledged, so state.)

3. Name and address of each transferor (if space is insufficient, incorporate and attach additional

sheets):

Aggregate number or amount of

securities proposed to be transferred

Name Address by each transferor:

Total: ____________________________________

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____________________________________________________________________________________

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

APPLICATION FOR CONSENT TO TRANSFER SECURITIES PURSUANT TO

SECTION 25151 OF THE CORPORATE SECURITIES LAW OF 1968

DFPI–260.151(a) (Register 2009, No. 39) (Rev. 11-20) Page 2 of 3

Name and address of each proposed transferee (if space is insufficient, incorporate and attach

additional sheets):

Aggregate number or amount of

securities proposed to be transferred

Name Address by each transferor:

Total: ____________________________________

Address of principal executive office of Issuer:

(Number and Street) (City) (State) (Zip Code)

Name and address of person to whom correspondence regarding this application should be

directed:

(Name) (Number and Street) (City) (State) (Zip Code)

There are attached hereto as exhibits statements by each of the proposed transferees in the

form required by Section 260.151 of Title 10 of the California Code of Regulations. (Note:

Upon request, such statements will be treated as confidential by the Commissioner, subject to

the provisions of Section 250.10, Title 10, California Code of Regulations.)

(Check appropriate box)

(a) There are no restrictions upon the transfer of the securities proposed to be transferred

other than the legend or escrow condition imposed by the Commissioner of Financial

Protection and Innovation.

(b) There are no restrictions upon the transfer of the securities proposed to be transferred

other than the legend or escrow condition imposed by the Commissioner of Financial

Protection and Innovation which are described in an exhibit attached hereto and

incorporated herein by reference. Such restrictions have been complied with as to

make the transfer to the proposed transferees valid and are known to the proposed

transferees.

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_________________________________________ ______________________________________

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

APPLICATION FOR CONSENT TO TRANSFER SECURITIES PURSUANT TO

SECTION 25151 OF THE CORPORATE SECURITIES LAW OF 1968

FPI–260.151(a) (Register 2009, No. 39) (Rev. 11-20)

Page 3 of 3

9. No portion of the consideration to be given by the transferees of the securities will be for the

direct or indirect benefit of the Issuer identified in Item 1. (If the Issuer is to benefit from

proposed transfer, see Section 25011 of the Corporate Securities Law of 1968 and Section

260.011 of Title 10, of the California Code of Regulations. Qualification of the transaction may

be required.

10. Execution Instructions:

If a transferor is other than an individual, the name of the entity should be typed or printed

above the signature line exactly as shown in Item 3. The signature should show the name and

title of the person authorized to sign for such transferor.

I/We certify (or declare) under penalty of perjury under the laws of the State of California and

I/We have read this application and know the contents thereof, and that the statements therein

are true and correct.

Executed at ________________________________________________, _____________, 20______

(Place) (Date)

(If the transferor is other than an individual, give the name of the entity and the name and title

of the person executing the application on behalf of such entity.)

(Signature of Transferor) (Signature of Transferor)