PLEASE COMPLETE THE FOLLOWING Clause Samples

PLEASE COMPLETE THE FOLLOWING. The undersigned hereby represents and warrants to the Company that the answers to the following questions are true and correct and that the Company may rely on such answers in deciding whether to accept this subscription.

PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ Wise & Company, please check the following box. |_| 2. The exercise of this Warrant was solicited by --------------------------------------------------------------- 3. If the exercise of this Warrant was not solicited, please check the following box. |_|

PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by Network 1 Financial Securities, Inc., please check the following box. |_| 2. The exercise of this Warrant was solicited by -------------------------------------------------------------------------------- 3. If the exercise of this Warrant was not solicited, please check the following box. |_|

PLEASE COMPLETE THE FOLLOWING. (a) The Business Day on which such Loan is to occur is __________, 2013. (b) The interest rate being selected in respect of such Loan shall initially bear interest at (check one (1) applicable box): [ ] LIBOR Rate plus the Applicable Margin [ ] Prime Rate plus the Applicable Margin (c) The payment instructions/wire instructions for the delivery of such Loan is as follows: ________________________ ________________________ ABA No.:________________ Account No.:_____________

PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by National Securities Corporation please check the following box [ ] 2. The exercise of this Warrant was solicited by [ ] -------------------------- 3. If the exercise of this Warrant was not solicited, please check the following box [ ] Dated: ______________________ X____________________________ ____________________________ ____________________________ Address ____________________________ Social Security or Taxpayer Identification Number ____________________________ Signature Guaranteed

PLEASE COMPLETE THE FOLLOWING. Has the Company or any of its Authorised Representatives or other representatives had a request for media accreditation (whether issued by DataCo or any other entity) declined, suspended or withdrawn? If “Yes”, please provide further details. Yes

PLEASE COMPLETE THE FOLLOWING. I prepared all of the pleadings and papers to be filed in this case myself, and no one has been, or will be, paid on my behalf. I have not paid anyone or any organization for the preparation and processing of these documents or for the forms to be used in this case. day of , 20 . Notary Public for State of Montana Residing at My Commission Expires: Hon. Fourth Judicial District Missoula County Courthouse ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇ Missoula, Montana 59802 (▇▇▇) ▇▇▇-▇▇▇▇ Fax (▇▇▇) ▇▇▇-▇▇▇▇ In re the Marriage of: , Co-Petitioner, and , Co-Petitioner. Dept. No. Cause No.: DR- ORDER ON INABILITY TO PAY FILING FEES AND OTHER COSTS Having considered the information contained in [ ] Wife [ ] Husband Co-Petitioner’s Affidavit of Inability to Pay Filing Fees and Other Costs, IT IS ▇▇▇▇▇▇ ORDERED that, pursuant to §▇▇-▇▇-▇▇▇, MCA et seq., all officers of the Court shall perform all services associated with this action, including filing, issuance and service of all pleadings and Court orders, without demanding or receiving fees in advance. Leave to file the Petition expires thirty (30) days from the date of this Order. Dated this day of , 20 . DISTRICT COURT JUDGE FORM #216 Name Address City State Zip Code Phone Number Email Address WIFE, CO-PETITIONER PRO SE Name Address City State Zip Code Phone Number Email Address HUSBAND, CO-PETITIONER PRO SE

PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ & Company, L.P. please check the following box / / 2. The exercise of this Warrant was solicited by / / -------------------------- 3. If the exercise of this Warrant was not solicited, please check the following box / / Dated: ______________________ X_________________________________ _________________________________ _________________________________ Address -------------------------------- Social Security or Taxpayer Identification Number -------------------------------- Signature Guaranteed --------------------------------

PLEASE COMPLETE THE FOLLOWING. (Caretaker will prepare facility per information supplied) 1. Number of people: a. attending the meal b. attending the function 2. Do you require: a. Full Hall b. P.A. System c. Kitchen d. Kitchen/Lobby e. Lobby/Former Ice Surface 3. Date and time(s) prior to the function: (i.e. decorating, bar supplies, caterers, a. Purpose: Time in: Time out: b. Purpose: Time in: Time out: 4. The actual date and time required for your function: a. Rental Day 1, Date: i. Time in (doors open to public): ii. Time out (doors locked): b. Rental Day 2, Date: i. Time in (doors open to public): ii. Time out (doors locked):