OTC IntelligenceTM – Order Form



[pic] OTCIQ Order Form – Services for Pink® Companies

Company Name:      

U.S. Trading Symbol:      

Address:      

City, State, Zip:      

Main Telephone:      

Company Website:      

State of Incorporation:      

Select Services

Real-time Level 2 Quote Display Service No Application Fee $3,000 Annual Fee

Sponsor Level 2 Quotes for your stock so investors can have free access to the same market data professional traders have. Broker-Dealer identifiers, bid and ask prices, and time & sales data delivered to investors on and on your corporate IR site – all in real-time.

OTC Disclosure & News Service® Distribute your Company’s news, research and financial reports to and other financial information portals, so that investors can analyze, value, and trade your Company’s stock. Select the Application Type:

New Application $2,500 Application Fee $5,500 Annual Fee or $3,500 Semi-Annual Fee

Change in Control[1] $2,500 Application Fee Annual Fee N/A

Subscribers are required to submit a new Order Form, Application Fee, board resolution verifying Change in Control and any other applicable documentation related to a change in Officers, Directors or Affiliates. Services may be suspended until OTC Markets has completed review of an Order Form following such Change in Control.

Change in Control or Court Appointed Custodian Disclosure: Subscribers are required to submit additional information if your Company is applying as a result of a Change in Control or has a Court Appointed Custodian. Information on this requirement can be found here.

Officers and Directors

Please provide a list of all Officers and Directors below.

If the Company has undergone a Change in Control Event, include the Former Officers and Directors immediately prior to the Change in Control and clearly indicate that they are former officers and directors. OTC Markets may contact the former management to confirm their resignation(s).

|Position |Full Name |Email |Phone |

|      |      |      |      |

|      |      |      |      |

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Control Persons: List all persons or entities owning 5% or more of any class of the issuer’s shares. If any are corporate shareholders or entities, you must also provide the name of the person(s) beneficially owning or controlling such corporate shareholders, or the name of an individual representing the corporation or entity. Beneficial Ownership includes the right to acquire the security within 60 days including, but not limited to, the exercise of options or warrants or through conversion. See Securities Exchange Act Rule 13d-3.

|Full Name |Number of Shares |% Shares Beneficially Owned |Class of Shares |

| |Beneficially Owned | | |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

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|      |      |      |      |

|      |      |      |      |

Transfer Agent Authorization

I have authorized the below named Transfer Agent to provide information directly to OTC Markets Group, upon its request, information related to the Company’s securities, including but not limited to, shares authorized, shares issued and outstanding, and share issuance history. Authorization is required to process this Order Form.

Firm Name:      

Address:      

Contact Name:      

Email:      

Phone Number:      

Confirm Review of Stock Promotion Policy and Best Practices

An officer of the Company has reviewed OTC Markets Group Policy on Stock Promotion and the Best Practices for Issuers.

Authorized User(s)

Designate persons below (each an “Authorized User”) to receive Company Credentials, which are required to access the OTC Disclosure & News Service and . In the event an Authorized User leaves the Company or otherwise is no longer an Authorized User, the Company must notify OTC Markets Group immediately to terminate access or assign a new Authorized User. Changes to Authorized Users should be made using the OTCIQ User Change Request Form via DocuSign. Authorized Users may not share Company Credentials.

Authorized User 1:

Name:      

Title/Affiliation:      

Email:      

Business Phone:      

Authorized User 2: (Optional)

     

     

     

     

Submit Application

Email the following application materials to OTC Markets Group at issuers@.

1. Completed OTCIQ Order Form

2. Current Shareholder List provided by your transfer agent

3. Background Check Authorization Form authorizing background checks on all Company Officers, Directors and Control Persons, as well as all Authorized Users indicated above and Billing Contacts.

4. If applying for services following a Change in Control as defined on Page 1, OTC Markets Group requests contact information for the Former Officers and Directors in the above table. You are also required to submit a board resolution and letter(s) of resignation(s). In addition, subscribers with a change in control or court appointed custodian are required to submit the Change in Control or Court Appointed Custodian Addendum.

Next Steps

1. Upon receipt of this Order Form, OTC Markets Group will send an invoice for the services applied for, to the Billing Contacts listed on Page 4. The invoice will contain instructions for payment by ACH/Wire, Check or Credit Card. OTC Markets Group will not review this Order Form until payment of the Application Fee is received.

2. OTC Markets Group may request additional information including a copy of Driver’s License or Passport for identity verification purposes, or any other documents related to this Order Form prior to providing Company Credentials. OTC Markets may, in its sole and absolute discretion, determine not to provide Company Credentials as requested on this Order Form.

3. Once the Order Form is ready for approval, an OTC Markets Group analyst will separately reach out via DocuSign to have the Company sign the OTCIQ Agreement.

4. We will verify your company information and provide Company Credentials and instructions to the Authorized User(s).

5. If applying for services following a Change in Control or Court Appointed Custodian, the Company will be asked to post the Change in Control or Court Appointed Custodian Addendum to your profile.

Access to this service does not guarantee that a company will move to the Current Information or Limited Information tier or that the Caveat Emptor designation will be removed.

OTCIQ Order Form - Payment Information

Fees

• Application Fees are non-refundable

• All Annual Fees are billed annually or semi-annually, in advance, as indicated by your selection on page 1

• The Application Fee and first Annual Fee/Semi-Annual Fee for services must be paid upon submission of this Order Form.

• No services will be entitled until funds are received.

OTC Markets Group will not review this application until payment of the Application Fee is received. You may submit payment in conjunction with your application per the below instructions.

ACH/Wire Payment Instructions

Customers that wish to send ACH payments to our account should use the following information:

JP Morgan Chase Money Transfer & Wire Department

4 New York Plaza New York, NY 10004 ABA

Routing Number: 021000021

Credit the Account of: OTC Markets Group Inc.

Account #: 764232302

Our bank’s SWIFT Code is: CHASUS33

To avoid delay in processing your payment, customers should include: (a) invoice number, if available or (b) OTCIQ Order Form, in the Memo Line/Special Instructions/Pay Detail of the wire transfer.

To ensure prompt and proper credits, we would appreciate customers sending payment detail (customer name or account number, invoice(s) paid, as applicable) to us via email at otcmarketsgroupbilling@ or via fax to (212) 868-3828.

Billing Contact

All invoices and billing notices will be sent by email to the contact(s) listed below.

| |Primary Billing Contact |Alternate Billing Contact |

|Name |      |      |

|Company Affiliation or Title |      |      |

|Address |      |      |

|City, State, Zip: |      |      |

|Email |      |      |

|Telephone |      |      |

For questions related to billing, you may contact OTC Markets Group Finance Department at 212-896-4405 or otcmarketsgroupbilling@.

Company Signature

I certify that the information contained in this OTCIQ Order Form is true and correct, and will notify OTC Markets Group promptly of any material changes. I further represent that any personal data provided herein has been collected, and is being shared with OTC Markets Group, in accordance with all applicable privacy laws (e.g. the required consent has been obtained from third parties).

|Signature of Company Officer: __________________________________________________ |

| |

|Date: |      |

|Print Name: |      |

|Company Name: |      |

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[1] “Change in Control” shall mean any events resulting in:

(i) Any “person” (as such term is used in Sections 13(d) and 14(d) of the Exchange Act) becoming the “beneficial ownerₔ愨⁳敤楦敮⁤湩删汵⁥㌱ⵤ″景琠敨䔠捸慨杮⁥捁⥴‬楤敲瑣祬漠⁲湩楤敲瑣祬‬景猠捥牵瑩敩⁳景琠敨䌠浯慰祮爠灥敲敳瑮湩⁧楦瑦⁹数捲湥⁴㔨┰
牯洠牯⁥景琠敨琠瑯污” (as defined in Rule 13d-3 of the Exchange Act), directly or indirectly, of securities of the Company representing fifty percent (50%) or more of the total voting power represented by the Company’s then outstanding voting securities;

(ii) The consummation of the sale or disposition by the Company of all or substantially all of the Company’s assets;

(iii) A change in the composition of the Board occurring within a two (2)-year period, as a result of which fewer than a majority of the directors are directors immediately prior to such change; or

(iv) The consummation of a merger or consolidation of the Company with any other corporation, other than a merger or consolidation which would result in the voting securities of the Company outstanding immediately prior thereto continuing to represent (either by remaining outstanding or by being converted into voting securities of the surviving entity or its parent) at least fifty percent (50%) of the total voting power represented by the voting securities of the Company or such surviving entity or its parent outstanding immediately after such merger or consolidation.

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