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Transfer Agent Verification Form. This is a Official Federal Forms form and can be use in FINRA.
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Transfer Agent Verification Form
Completion of this form certifies to FINRATM notification of a corporate action (e.g., a name change, stock split, and/or spin-off) for
an OTC issuer. This form is required to be filled out and submitted by the transfer agent only.
Transfer Agency:
*Required Field
AGENCY NAME:*
Yes
IS TRANSFER AGENCY A SEC REGISTERED AGENT?*
No, please confirm where registered:
AGENCY ADDRESS:*
AGENCY REPRESENTATIVE:*
TELEPHONE:*
TITLE:*
FACSIMILE:
EMAIL:*
WEBSITE:*
WHERE DID THE AGENT RECEIVE NOTIFICATION FROM? *
OTC Issue Requiring Change:
ISSUER
LEGAL COUNSEL
OTHER
*Required Field
COMPANY NAME : *
ADDRESS: *
CITY:*
ZIP/POSTAL CODE:*
STATE/PROVINCE:*
COUNTRY OF INCORPORATION:*
IF US, STATE OF INCORPORATION:
DATE OF INCORPORATION OR RE-INCORPORATION:*:
CONTACT NAME:*
TELEPHONE:*
TITLE:*
FACSIMILE:
Appointment Verification:
EMAIL:*
*Required Field
DATE OF APPOINTMENT AS TRANSFER AGENT:*
If date of appointment is within last six months, please provide the following information:
PRIOR TRANSFER AGENT:
DATE RECORDS WERE TRANSFERRED AND RECEIVED FROM PRIOR AGENT:
TRANSFER AGENT VERIFICATION FORM REV. (03/09)
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Transaction Options (please fill out all that apply):
Name Change:
NEW COMPANY NAME:
CUSIP/CINS NUMBER(S):
CURRENT:
NEW:
ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * *
Stock Split:
FORWARD SPLIT PAYABLE UPON SURRENDER OF OLD CERTIFICATES
CUSIP/CINS NUMBER(S):
CURRENT:
NEW:
STOCK SPLIT RATIO:
FORWARD SPLIT - NEW SHARES ALLOCATED/MAILED DIRECTLY TO SHAREHOLDERS
CUSIP/CINS NUMBER(S):
CURRENT:
NEW:
RECORD DATE:
PAYABLE DATE:
STOCK SPLIT RATIO:
REVERSE SPLIT
CUSIP/CINS NUMBER(S):
CURRENT:
NEW:
RECORD DATE:
PAYABLE DATE:
STOCK SPLIT RATIO:
The following information is required for all stock splits:
PRE-SPLIT TOTAL SHARES OUTSTANDING:
AS OF DATE:
POST-SPLIT TOTAL SHARES OUTSTANDING:
AS OF DATE:
METHOD OF SETTLING FRACTIONAL SHARES:
ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * *
Any conditions which must be met for the transaction to become effective:
Spin-Off:
SPIN-OFF COMPANY NAME:
PARENT ENTITY:
CUSIP/CINS NUMBER(S):
Spin-Off Company:
Parent Entity:
RELATIONSHIP BETWEEN SPIN-OFF AND PARENT ENTITY:
ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * *
** NOTE: Processing of Corporate Action prior to announcement on the OTCBB or OTC Daily List may result in subsequent clearance
and settlement issues.
TRANSFER AGENT VERIFICATION FORM REV. (03/09)
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Other (please specify):
Stock Certificate Verification:
*Required Field
ARE THE EXISTING SHARES DEPOSITORY ELIGIBLE AND HELD AT DTC?*
Yes
No
CAN DTC HOLD THE NEW CERTIFICATES IN NOMINEE NAME? *
Yes
No
IS THE SURRENDER OF CERTIFICATES MANDATORY?*
Yes, please specify effective date:
No
WHEN WILL NEW INVENTORY BE AVAILABLE?*
ARE THERE ANY RESTRICTIONS ON THE NEW SHARES?*
Yes, please specify (i.e., 144, legend, etc.):
No
Authorization by Transfer Agent Representative:
*Required Field
, hereby certify that all requirements by the Transfer Agent have been
I *,
satisfied to process the transaction and that all the information disclosed in this request is accurate and true.
SIGNATURE:*
DATE:*
Submission of Transfer Agent Notification:
FINRA
Operations, 5th Floor
9509 Key West Avenue
Rockville, MD 20850
Telephone: 1.866.776.0800
Fax: 202.689.3533
Email: OTCcorpactions@finra.org
E-mail Submit
Print Form
TRANSFER AGENT VERIFICATION FORM REV. (03/09)
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