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Registration By Qualification Document And Disclosure Checklist Form. This is a Georgia form and can be use in Blue Sky Secretary Of State.
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Tags: Registration By Qualification Document And Disclosure Checklist, 8Q, Georgia Secretary Of State, Blue Sky
SECURITIES AND BUSINESS REGULATION
237 Coliseum Drive
Macon, Georgia 31217-3858
Atlanta, Georgia 30334
(478) 207-2440
http://www.sos.ga.gov/securities/
BRIAN P. KEMP
Commissioner of Securities
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REGISTRATION BY QUALIFICATION
Document and Disclosure Checklist
Georgia Securities Act of 2008, As Amended
O.C.G.A. §10-5-23
Office Use ONLY
Control
#:
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Examiner: __________
APPLICANT:
Description of Document/Disclosure
OCGA 10-5-
1. ADVISORY DIRECTORS
A. Written Consent
B. Description of Relationship
C. Compensation
(5)(c)(1)(C)
2. APPLICATION FOR REGISTRATION
A. Complete all Applicable Parts of Form 8 B. Document
and Disclosure Checklist C. Manual Signatures of
Officers and Directors
23(b)
3. BOND/FINANCIAL RESPONSIBILITY
A. Bond -- $25,000
B. Certificate of Deposit -- $25,000
C. Other
6(b)
5(b)(2)
4. CAPITALIZATION
A. Within 90 days
B. Adjusted for Proposed Offering
C. Statement of Consideration Received for Securities Issued in
the Past Two Years
5. CORPORATE DOCUMENTS
A. Articles of Incorporation
B. Bylaws
C. Management Contracts
D. Indenture or Other Instrument Relating to the Securities to be
Registered
D. Consent to Service of Process
E. Date and Place Organized
23(b)(7)
6. COMPETITIVE CONDITIONS STATEMENT
23(b)(1)
7. CONFIDENTIAL TREATMENT REQUEST
76(b)(2)
8. DESCRIPTION OF OFFERING
A. Type of Securities
B. Number Offered
C. Offering Price and How Computed D.
Aggregate Offering
E. General Purpose of Offering F.
Specific Use of Proceeds
G. Commissions, Discounts and Expenses of Offering
23(b)(8)
23(b)(14)
23(b)(14)
23(b)(11)
23(b)(14)
23(b)
23(b)(1)
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Form 8Q Rev 2/2011
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Control
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Examiner: __________
APPLICANT:
9. DIRECTORS, OFFICERS, CONTROL PERSONS, PROMOTERS
A. Form 8-1 for each director or other persons performing similar
functions
B. Form 8-1 for each officer
C. Form 8-1 for each person owning 10% or more of the
outstanding shares of any class of equity security of the issuer
D. Form 8-1 for each promoter
E. Compensation to three highest paid officials
F. Material interest in any material transaction, within past three
years, or any proposed transaction
23(b)(2)
23(b)(4)
23(b)(5)
23(b)(3)
23(b)(2)
10. ESCROW
A. Minimum Business Plan
B. Agreement to Escrow Securities
C. Agreement to Escrow Proceeds D.
Petition for Waiver of Escrow
E. Letter from Escrow Agent Regarding Release of Funds
Notification
6(e) and
590-4-3-.01
5(c)(1)(K)
11. FEES
A. Initial Registration - 1/20 of 1% of Aggregate Offering
(Minimum $250)
B. Renewal - $100
C. Additional Assessments
D. Reports - $10
12. FINANCIAL STATEMENTS
A. Balance Sheet Certified by Independent Public Accountant
B. 90 Day Unaudited Balance Sheet
C. Profit and Loss Statement
D. Analysis of Surplus
E. Statement of Financial Condition
F. Acquired Business Financials
G. Projections and Forecasts
10-5-23; Uniform Act
Imp. Order 2009-09
13. LEGAL AND PROFESSIONAL OPINIONS AND STATEMENTS
A. Legal opinion that securities to be sold will be fully paid and
nonassessable and, if debt security, a binding obligation of the
issuer
B. Written consent by anyone whose opinion or statement will be
used in connection with the offering
14. LEGENDS
A. Rescission
B. Disclaimer
C. Forecasts and Projections
15. LITIGATION, MATERIAL
A. Issuer
B. Officers, Directors, Affiliates
“
590-4-3-.08
23(b)(17)
23(b)(15)
23(b)(16)
5(c)(1)(P)
6(d)
23(b)(12)
23(b)(2)
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Form 8Q Rev. 2/2011
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APPLICANT:
16. NEGOTIABLE INSTRUMENTS
19
17. PROSPECTUS
A. Draft Copy
B. Three Final Dated Copies
C. Sales Literature
D. Literature for Selling Group
23(b)(13)
18. RISK FACTORS
A. Competition
B. Litigation
C. Conflicts
D. Key Officials
E. Investigative Proceedings
F. Market Conditions
G. Tract Record
H. Dilution
23(b)
19. SELLING SHAREHOLDERS
A. Name and Address
B. Amount of Securities Owned
C. Relationship to Issuer
23(b)(6)
20. SPECIMEN OF SECURITIES TO BE ISSUED
23(b)(14)
21. STOCK/SECURITY OPTIONS DESCRIPTION
23(b)(10)
22. STOCK SUBSCRIPTION AGREEMENT
5(c)(2)(B)
23. UNDERWRITING OR SELLING GROUP AGREEMENT
23(b)(8)
24. USE OF PROCEEDS
Form 8Q Rev. 2/2011
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23(b)(9)
Page 3 of 3
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