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Please fill out and submit the following information so we may better assist you.

You may either click here now to email us your documents for EDGAR conversion as attachments or you can fill out the information below and we will contact you. Thank you and you will hear back from us shortly.

Company Name:
Contact Person
First Name: Last Name:
Street Address:
City: State:
Zip Code: Email Address:
Business Phone: Cell Phone:
SEC Form Type: Conversion Type:
Company's EDGAR Codes: CIK CCC Individual's EDGAR Codes: CIK CCC
(Individual EDGAR Codes are needed for documents such as Form 3, 4 and SC13D.)
Fiscal Year End:
When do you plan to file this document with the SEC?
Shall we charge this filing to your credit card on file?      Yes No
Credit Card Information (if not on file)
Name of Card Holder: Card Type:
Card Number: Expiration Date:

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