Legal Entity Formation Form

1.) Name of the Company or Private Interest Foundation / 3 Suggestions in Order of Preference:

2.) Purpose for Which the Company or Private Interest Foundation is Being Established

3.) Main Countries in Which the Company or Private Interest Foundation Will Conduct Transactions or Activities:

In case of using the Company or Private Interest Foundation for investments or holding, please describe the specific activities, type of investments, products, goods and assets involved.

4.) Will this Company or Foundation Be Part of a Legal Structure?

If yes, provide the name and jurisdiction of the structure:

5.) Directors/Officers/Board Members/Names and Addresses

* All the above individuals must complete the Due Diligence Form.

6.) Share Capital

NOTE: THE LAW DOES NOT REQUIRE THE SHARE CAPITAL TO BE PAID UP OR DEPOSITED ANYWHERE.

Specify your preferences:

7.) Type of Shares:

If you require an additional number of share certificates, please specify the quantity and in whose name:

8.) Shareholders

* All Shareholders must complete the Due Diligence Form.

9.) Ultimate Beneficial Owners

I declare under penalty of perjury that the Ultimate Beneficial Owner(s) of the legal entity described here is (are) the same as the shareholder(s): Yes No

If different from the aforementioned shareholder(s), please provide:

* All Ultimate Beneficial Owners must complete the Due Diligence Form.

10.) Contact Person / Person to Be Contacted Regarding the Legal Entity and Address for Sending Documentation

11. General Power of Attorney Options:

Registered with the Public Registry: Yes No

(If more than two persons, specify whether the representation of the power is individual or joint.)

12.) General Power of Attorney

13.) Optional Additional Services:

14.) If You Require Any Other Additional Service:

Declaration

I, (full name), declare that:

1. To the best of my knowledge, the information provided here is correct and true, and I assure that the source of the funds with which I pay and/or transfer to Violeta Annet Holness for her fees and/or costs do not come from drug trafficking and/or terrorist activities and/or money laundering and/or proliferation of weapons of mass destruction.
2. None of the services provided by Violeta Annet Holness will be used in activities related to drug trafficking and/or terrorism and/or money laundering and/or proliferation of weapons of mass destruction.
3. The information I have provided is truthful and verifiable.

Signature: Date:

Violeta Annet Holness reserves the right not to provide the services or to discontinue their provision and/or to resign from her position as Resident Agent and/or any other corporate service at any time in case incorrect, incomplete, or untruthful information has been provided and/or if the services rendered are used for illicit activities such as drug trafficking and/or terrorist activities and/or money laundering and/or proliferation of weapons of mass destruction.