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Application To Register Securities Form. This is a Connecticut form and can be use in Blue Sky Secretary Of State.
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Tags: Application To Register Securities, CT3, Connecticut Secretary Of State, Blue Sky
Form U-1 or CT-3
APPLICATION TO REGISTER SECURITIES
Application to the Department of Banking of the State of Connecticut pursuant to The Connecticut Uniform
Securities Act.
For Filing By: (check one)
Coordination - Section 36b-17
Qualification - Section 36b-18
1. Name and address of Issuer:
Principal office in this State:
2. Name, address and telephone number of correspondent to whom notices and communications regarding this
application may be sent:
3. Name and address of applicant:
4. Registration or acceptance for filing is sought for the following described securities in the amounts indicated:
Offering Price
or Proposed
Offering Price
Description of
Securities
Total Offering
No. of Shares
or units
Amount
Offering in this state
No. of Shares
or units
Amount
$
$
Totals
Indicate the maximum commission to be charged:
$
$
%
5. Amount of filing fee which is enclosed: $
(One-tenth of one percent of the maximum aggregate offering amount in Connecticut:
Minimum $300.00/Maximum $1500.00)
6. A Registration Statement (was filed) (is expected to be filed) with the Securities and Exchange Commission
on
and is expected to become effective on or about
(date)
.
(date)
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7. (a) List the states in which it is proposed to offer the securities for sale to the public:
(b) List the states, if any, in which the securities are eligible for sale to the public.
(c) List the states, if any, which have refused, by order or otherwise, to authorize sale of securities to the
public, or have revoked or suspended the right to sell the securities, or in which an application has been
withdrawn.
8. Submitted herewith as a part of this application are the following documents (documents on file may be
incorporated by reference):
(a) One copy of the Registration Statement and (3) copies of Prospectus in the latest form on file under the
Securities Act of 1933.
(b) Agreement Among Underwriters, Underwriting Agreement, and Selected Dealers Agreement.
(c) Indenture.
(d) Issuer's charter or articles of incorporation as amended to date.
(e) Issuer's by-laws as amended to date.
(f) Signed copy of opinion of counsel filed with Registration Statement pursuant to the Securities Act of
1933.
(g) Specimen (type of security).
(h) Consent to Service of Process accompanied by the appropriate corporate resolution.
(i) If an earning computation or similar requirement is required to be met in this state, attach a separate
sheet as an exhibit showing compliance.
(j) One copy of all advertising matter to be used in connection with the offering.
(k) Others (list each):
9. The applicant hereby applies for registration or acceptance for filing of the above registered securities under
the law cited above and in consideration thereof agrees so long as the registration remains in effect that it
will:
(a) Advise the above named state authority of any change prior to registration in this state in any of the
information contained herein or in any of the documents submitted with or as a part of this application.
(b) File with the above named state authority within two business days after filing with the Securities and
Exchange Commission (i) any amendments other than delaying amendments to the federal registration
statement, designating the changed, revised or added material or information by underlining the same; and
(ii) the final prospectus, or any further amendments or supplements thereto.
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(c) Notify the above named state authority within two business days (i) upon the receipt of any stop order,
denial, order to show cause, suspension or revocation order, injunction or restraining order, or similar order
entered or issued by any state or other regulatory authority or by any court, concerning the securities
covered by this application or other securities of the issuer currently being offered to the public; and (ii) upon
the receipt of any notice of effectiveness of said registration by the Securities and Exchange Commission.
(d) Notify the above named state authority at least two business days prior to the effectiveness of said
registration with the Securities and Exchange Commission of (i) any request by the issuer or applicant to any
other state or regulatory authority for permission to withdraw any application to register securities described
herein; and (ii) a list of all states in which applications have been filed where the issuer or applicant has
received notice from the state authority that the application does not comply with state requirements and
cannot or does not intend to comply with such requirements.
(e) Furnish promptly all such additional information and documents in respect to the issuer or the securities
covered by this application as may be requested by the above named state authority prior to registration or
acceptance for filing.
Date:
Name of Applicant
By
(Name and Title)
State of
)
)
)
)
County of
ss
)
The undersigned,
duly sworn, deposes and says:
, being first
That he has executed the foregoing application for and on behalf of the applicant named therein; that he is the
of such applicant and is fully authorized to execute and file such
application; that he is familiar with such application; and that to the best of his knowledge, information and belief
the statements made in such application are true and the documents submitted therewith are true copies of the
originals thereof.
Name
Subscribed and sworn to before me this
day of
, 20
.
NOTARY PUBLIC
My Commission Expires:
(Notarial Seal)
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FOR AN ACKNOWLEDGMENT OF THE FILING
OF THIS APPLICATION COMPLETE THE LEFT COLUMN BELOW
Name and address of correspondent
State of
File Number
Applicant
Date
Examiner
Issuer
Telephone
Name of any broker-dealer or agent of issuer registered to do business under this chapter who may offer the
securities in this state:
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