1. 發行人的身份

2. 業務的主要地點和聯繫信息

3. 相關人員

如果需要的話，回覆的澄清：

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4. 行業板塊

5. 發行人規模

6. 申報的聯邦豁免和排除（選擇所有適用項）

7. 申報類型

8. 提供的持續時間

9. 提供的證券類型（選擇所有適用項）

10. 業務合併交易

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11. 最低投資額

12. 銷售補償

13. 提供和銷售金額

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14. 投資者

15. 銷售佣金和介紹費用支出

單獨提供銷售佣金和尋找者費用支出的金額（如果有的話）。如果支出金額未知，請提供一個估算值，並在金額旁邊的框內打勾。

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16. 使用收益

提供已用於或擬用於向上述第3項要求列名的任何高級職員、董事或推廣人支付的發行毛收益金額。如果金額未知，請提供估計並在金額旁邊勾選框。

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簽名和提交

請核實您輸入的信息，並在簽名和點擊下面的提交按鈕以提交此通知之前查看以下提交條款。

提交條款

Each Issuer identified above has read this notice, knows the contents to be true, and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person.

For signature, type in the signer's name or other letters or characters adopted or authorized as the signer's signature.

Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.

* This undertaking does not affect any limits Section 102(a) of the National Securities Markets Improvement Act of 1996 ("NSMIA") [Pub. L. No. 104-290, 110 Stat. 3416 (Oct. 11, 1996)] imposes on the ability of States to require information. As a result, if the securities that are the subject of this Form D are "covered securities" for purposes of NSMIA, whether in all instances or due to the nature of the offering that is the subject of this Form D, States cannot routinely require offering materials under this undertaking or otherwise and can require offering materials only to the extent NSMIA permits them to do so under NSMIA's preservation of their anti-fraud authority.