Authorization Declaration Form

, the authorized individual to perform a MSB services

Transaction(s) on behalf of

, providing the following identification,

affirm that:

and I have been directed by such company to conduct business with Order Express, Inc.
in the form of MSB services.

2. I am providing this Affidavit to Order Express, Inc. as evidence of my ability to act on
behalf of said company.

3. I am providing this Affidavit to Order Express, Inc. as evidence of my ability to act on
behalf of said company.

AFFIRMATION

The foregoing statements have been completed and carefully read by the undersigned and I affirm that the foregoing is true and correct. I further solemnly affirm under the penalty of perjury that the above information is true to the best of my knowledge, information and belief.