1. Name of Company:

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2. Date of Incorporation:

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   Registered Office:

   Name: Professional Corporate Services (Anguilla) Ltd.

   Address: The Hallmark Building. Box 227, Anguilla, B.W.I.

   Code No.

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3. Registered Agent:

   Name: Professional Corporate Services (Anguilla) Ltd.

   Address: The Hallmark Building. Box 227, Anguilla, B.W.I.
   

   Code No.

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4. Fee:

   _____ No Par Value and No Authorized Share Capital

   _____ Authorized Capital Exceeds US$50,000.00

   _____ Par Value and/or No Par Value Shares-Authorized Capital does not Exceed US$50,000.00
   

   Fee Submitted:

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5. Person Completing Return:

   Name:

   Address:

   Signature:

   Date:

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Company No:

Agent Code No.

Date Filed: