Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application To Register Securities Under Regulation 3 AAC 08.500-505 Form. This is a Alaska form and can be use in Blue Sky Secretary Of State.
Tags: Application To Register Securities Under Regulation 3 AAC 08.500-505, 08-101, Alaska Secretary Of State, Blue Sky
STATE OF ALASKA DEPARTMENT OF COMMERCE, COMMUNITY, AND ECONOMIC DEVELOPMENT DIVISION OF BANKING AND SECURITIES PO BOX 110807, JUNEAU, ALASKA 99811-0807 Phone (907) 465-5450 https://www.commerce.alaska.gov/web/dbs/Securities.aspx APPLICATION TO REGISTER SECURITIES UNDER REGULATION 3 AAC 08.500-505. INSTRUCTIONS. Use this registration statement form for offerings under 3 AAC 08.503(a). Attachments should be used where space is insufficient. Include as an attachment a completed Form U-2 (Uniform Consent to Service of Process) designating the Alaska Administrator of Securities as agent. Do not send offering documents unless requested by the Division staff. 1. FEES. Filing Fee: $600.00 for one year: $ Plus $75.00 per issuer salesperson, if any:* (*See 3 AAC 08.503(b)(2)) TOTAL FEES (Payable to State of Alaska): 2. $ $ ISSUER. Name, address, and telephone number of the issuer, or issuer to be formed, and principal office, if any, in this state. State the name under which the offering will be known. (Where required, issuers must file appropriate name reservation or organizational documents before an order may be issued pursuant to this application): 3. CORRESPONDENT. Name, address and telephone number of attorney or other correspondent to whom communications regarding this application should be sent: E-mail address: If more space is needed for any section, go to last page, indicate ¶, complete. 08-101 (01/16) Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 4. SECURITIES TO BE OFFERED. Check one: Common Stock, $ par value. Preferred Stock. Units of Limited Partnership Interest. Units of Limited Liability Company membership. Other--Please describe: 5. AMOUNT OF SECURITIES TO BE OFFERED. a. Total Offering Proposed Offering Price No. of Shares or Units Amount No. of Shares or Units Amount Alaska b. Manner of Payment. Will deferred payments be allowed to purchasers? Yes No If yes, please provide details. 6. ALASKA AND FEDERAL STATUS. Give the specific provisions of Alaska regulation 3 AAC 08.500, Article 4, and the specific provisions of Federal statutes and regulations under which this offering is to proceed: Alaska: (check one) 3 AAC 08.504(5) 3 AAC 08.504(6) 3 AAC 08.505(b) 3 AAC 08.505(c) Federal: 08-101 (01/16) Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 7. OTHER STATE TRANSACTIONS. a. List the other states in which these securities will be offered or where previous offers or sales have occurred and show whether the sales will be under state registration or exemption: b. List the states, if any, which have refused, by order or otherwise, to authorize sale of these securities, or have revoked or suspended the right to sell these securities, or in which an application for registration or exemption has been withdrawn. Provide full details: 8. BROKERS-DEALERS OR SALESPERSONS. a. Name, address, and telephone number of broker-dealer registered in Alaska and lead broker-dealer, if any. Indicate whether or not broker-dealer is a member of NASD. NASD member? Yes No b. Where registered issuer salespersons (agents), or persons claiming an exception from the definition of agent are to be used, give their names, addresses, and telephone numbers and indicate their registration status or exempt status in Alaska. Where a statutory exception is claimed, give the specific Alaska provision: 08-101 (01/16) Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 8b continued: Note: An order of registration will only be issued when registration of issuer salespersons (agents), if required, is completed. 9. PROFESSIONALS INVOLVED. Give the names, addresses, and telephone numbers of all professionals who have rendered services or have given advice in connection with this offering, who are named as experts in sales literature or presentations, or whose names are used to give authority to statements made concerning this offering. Describe their scope of activities. Include attorneys, accountants, appraisers, engineers, etc: 10. BUSINESS PLAN. Briefly describe the nature of the business to be conducted with the proceeds of this offering: 08-101 (01/16) Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 11. USE OF PROCEEDS: Dollar Amount MAX MIN Percentage MAX MIN Selling Commissions Other Selling Expenses Legal, Accounting, Printing, Fees Offeror/Promoter Compensation Reserves The remaining Funds will be used as follows: Total Issuer represents that the minimum amount that must be raised before the project can get under way is $ and that a proceeds escrow under 3 AAC 08.502(g) has been established in that amount. (Leave blank if waiver is sought or show "none" if escrow is not required.) 12. INTEGRATION. Were any securities of the issuer sold within the six months preceding this registration? Yes No Note: Securities issued pursuant to certain employee benefit plans are excluded, see 3 AAC 08.502(a)(8). If the answer is yes, show how many counting purchasers were involved during the year preceding this registration. (Include dates of sale). If sales were made during the past year, provide arguments against integration of the prior sales, if this is desired. See 3 AAC 08.502(a)(1) for elements to consider. 08-101 (01/16) Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 13. AGGREGATION. Have any securities of the entity that will issue the securities in this registration been sold within the twelve months preceding this registration? Yes No What is the aggregate offering price? $ See 3 AAC 08.501(a)(3) for definition of aggregate offering price. 14. ACTIONS AGAINST ISSUER AND AFFILIATED PARTIES. a. Indicate "no" or "yes" and provide details if "yes" should any one or more of the items listed under subsection "b" apply to any one or more of the following parties: (I) the issuer, (ii) the predecessors or affiliates of the issuer, (iii) the issuer's, officers, directors, general partners, promoters, or beneficial owners of ten percent or more of any class of its equity securities. b. Actions: No (1) has filed a registration statement which is the subject of a currently Yes effective stop order entered by any state or federal agency within five years prior to the registration of the offering Yes No (2) has been convicted, within the ten years preceding the registration, of any felony; a misdemeanor in connection with the purchase or sale of a security or involving a false filing with a state No (3) is subject to any state administrative order or judgment or any federal Ye