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Application To Offer Or Sell Securities Form. This is a Georgia form and can be use in Blue Sky Secretary Of State.
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Tags: Application To Offer Or Sell Securities, 8, Georgia Secretary Of State, Blue Sky
SECURITIES AND BUSINESS REGULATION
237 Coliseum Drive
Macon, Georgia 31217-3858
(478) 207-2440
http://www.sos.ga.gov/securities/
BRIAN P. KEMP
Commissioner of Securities
APPLICATION TO OFFER OR SELL SECURITIES FORM 8
Georgia Uniform Securities Act of 2008, as amended O.C.G.A. §§ 10-5-21, 10-5-22 and 10-5-23
Name of Issuer:
A. Types of Filings and Fees
Check
One
Type
Amount
Enclosed
Required Fee
Registration by Qualification - O.C.G.A. §10-5-23
1/20 of 1% aggregate offering (Minimum $250)
Registration by Coordination - O.C.G.A. §10-5-22
$250 (Nonrefundable) (Use Form U-1)
Small Issue Registrant - O.C.G.A. §10-5-23
1/20 of 1% aggregate offering (Minimum $250)
Uniform Limited Offering Exemption - O.C.G.A. §10-5-21(c)
$250 (Nonrefundable) (Use Form D)
Renewals - O.C.G.A. §§10-5-22; 10-5-23
$100 (Nonrefundable)
Nonprofit Issuer Registration - O.C.G.A. §10-5-23
None Required
Nonprofit Issuer Renewal - O.C.G.A. §10-5-23
None Required
(Please make all checks payable to: COMMISSIONER OF SECURITIES, STATE OF GEORGIA)
B. General Information
1. Name & Address of Issuer:
Name
Phone Number
Address
City
State
Zip
2. Name, Address and Phone Number of Correspondent to whom notices and communications regarding this application may be sent:
Name
Phone Number
Address
City
State
Zip
State
Zip
3. Name and Address of the Applicant:
Name
Phone Number
Address
City
4. Registration or acceptance for filing is sought for the following described securities:
Total Offering
Description of
Securities
Form 8 Rev. 2/2011
Offering Price or
Proposed Offering
Price
Number Of Shares
or Units
Offering in Georgia
Amount
Number of Shares
or Units
Amount
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5. Type Organization (Check One Type and include all requested information.)
Corporation
Partnership
Trust
Other
Limited Partnership
Date Incorporated /Organized
Place Incorporated/Organized
(If Limited Partnership, Include County,
Book and Page Number recorded)
Name and Address of the Registered Agent:
Name
Phone Number
Address
City
State
Zip
6. A registration was filed with the Securities and Exchange Commission on ________________and will be effective on __________ __.
7. List the states in which it is proposed to offer the securities for sale to the public:
8. List the states, if any, in which the securities are eligible for sale to the public:
9. 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
securities, or in which an application has been withdrawn:
10. General character and location of issuer's business:
C. Documents Required By All Applicants
Submitted herewith as a part of this application are the following applicable documents. Any document filed within the last five years may be incorporated herein by reference,
to the extent that the document is currently accurate. It is requested, to the extent possible, that all documents be filed on standard (8 ½ x 11) letter size paper and that all
copies be clear and legible.
1.
A filing fee as set forth in Part "A" of this application. Nonprofit issuer registrations do not require a fee.
2.
An irrevocable Consent to Service of Process (Form U-2 or GA Form 6)
3.
If the issuer is a corporation, a director's resolution providing irrevocable corporate consent to service of process. (Form U-2A or
GA Form 6A)
4.
A copy of the proposed prospectus, offering circular, placement memorandum or other similar document.
5.
Copies of documents required by the applicable code section or rule.
Form 8 Rev. 2/2011
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D. To Be Signed By All Applicants
This application is filed pursuant to the Georgia Uniform Securities Act of 2008, as amended. The application must be signed by
an authorized agent of the issuer, any person on whose behalf the offering is to be made, a registered broker-dealer, or an
authorized agent of any of the above. If this application is signed by an agent, submit a copy of a Power of Attorney authorizing
the agent to execute the application.
This _____________________Day of ______________________________, 20____________________
(SEAL)
(Name of Applicant)
ATTEST/Witness:
(Authorized Signature)
(Title of person Signing Application)
E. Additional Signatures
Additional signatures required for registration pursuant to O.C.G.A. §§10-5-23. DO NOT COMPLETE THIS SECTION FOR
SEC Coordinated Filing Exemptions or Uniform Limited Offering Exemption filings (SEC Regulation D, Rules 505 & 506).
Signature
Title
Date
Chief Executive Officer
Principal Financial Officer
Comptroller or Principal Accounting Officer
Form 8 Rev. 2/2011
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This registration statement must be signed below by a majority of the issuer's Board of Directors or persons performing similar functions or, if
there is no Board of Directors or persons performing similar functions, by the majority of the persons or board having the power of management of
the issuer. For any member not signing, there must be attached, a written consent from such person to the filing of this registration statement and
use of his/her name therein. (If additional space is needed, attach a separate page with heading, "Signature Page Number Two".)
Signature
Title
Date
Form 8 Rev. 2/2011
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