From:__________________________________________________________

Address:_____________________________________Apt./Suite:_______

State/Province:________________________

Zip/Postal Code:_______________________

Country:_______________________________

Phone:_________________________________

FAX:___________________________________

Email:_________________________________

Other:_________________________________

Preferred Company Name

(1):___________________________________________________________

Alternate Company Name

(2):___________________________________________________________

Special Instructions:__________________________________________________

_______________________________________________________________

Please establish an International Business Company with broad powers using a name as I have indicated or which is convenient for you and acceptable to the Registrar of Companies in Belize.

• Corporate Nominee Shareholders and Corporate Nominee Directors should be used;
• The authorized capital should be the minimum allowed by law;
• There should be one bearer share issued;
• A Power of Attorney should be executed to provide me/us with Power to act in all matters for the company. This should be accompanied by the appropriate minutes showing that the Power was granted;
• A document, enclosed, transferring certain Power to Act for the company should be executed. This document should be forwarded as agreed;
• Having established the company, please forward a copy of the Memorandum of Association and Articles of Incorporation to me/us a the above address or as otherwise instructed in writing by me/us, and include: A copy of the Certificate of Incorporation and a copy of the Bearer Share Certificate;
• The original of all the documents and the Corporate Seal, except for the Power of Attorney should be held by you along with the original of the Bearer Share Certificate until the loan has been satisfied as agreed. For the services requested we have sent to United Offshore Services, Ltd., funds as follows:

____US$1,500 For forming the Company

____US$500 For the Trust Requested on the accompanying form

#:______________________

Your prompt attention to this request would be greatly appreciated:

Signed:_____________________________________________________

DATE: ___________________

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For Office Use: DATE RECEIVED:___________________

Entered:_______________________

ACKNOWLEDGE RECEIPT OF: $ ____________________Referred by:

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