Directions:

1) Complete form (Illegible forms will not be processed)

2) Mail or Fax completed form (a confirmation letter will be sent in 5 business days):

OneShare.com^®
3450 Third Street, Building 1D
San Francisco, CA  94124
FAX: 415.777.1677

Purchaser Information                                                     Shareholder Information

______________________________________                      ____________________________________
Purchaser Name                                                                Shareholder Name

______________________________________                      ____________________________________
Address Line 1                                                                   Address Line 1

______________________________________                      ____________________________________
Address Line 2                                                                   Address Line 2

______________________________________                      _____________________________________
City/State/Zip                                                                     City/State/Zip

______________________________________                      _____________________________________
Telephone (Daytime)                                                           Custodian (if shareholder is under 18)

______________________________________
Email Address


Ship to:

Purchaser____   Shareholder____   Other____

Payment Information (Checks orders are delayed due to bank processing and clearing):

Visa __ MasterCard __ AmEx ___ Diners ___   Cardnumber: ____________________  Expiration: __/____


                                                                                         

Please complete the information legibly on the next page:

Preferred Shipping Address                                         Plaque Inscription (40 characters per line)

_____________________________________                     _____________________________________
Name

_____________________________________                     _____________________________________
Address

_____________________________________                     _____________________________________
City/State/Zip

_____________________________________                     _____________________________________
Telephone (Daytime)

_____________________________________                    4 Lines of Text Only
Email Address