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Application To Register Securities Form. This is a Hawaii form and can be use in Blue Sky Secretary Of State.
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Tags: Application To Register Securities, Hawaii Secretary Of State, Blue Sky
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Registration Fee - $200.00
Index No.
Dishonored Check - $15.00 Fee
Plus Interest Charge
STATE OF HAWAII
:
Calendar No.
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
Business Registration Division
1 01 0 Richards Street, Honolulu, Hawaii 96813
:
Plaintiff(s)
Phone (808) 586-2730
JUDICIAL SUBPOENA
-against-
:
APPLICATION TO REGISTER SECURITIES
:
PURSUANT TO SECTION 485(6), HAWAII REVISED STATUTES
AND SUBCHAPTER 10, CHAPTER 38, HAWAII ADMINISTRATIVE RULES
:
Defendant(s)
:
......................................................
INSTRUCTIONS. Use this form for registering Regulation D offerings under Section 485(6), Hawaii Revised Statutes and
Subchapter 10, Chapter 38, Hawaii Administrative Rules. Attachments should be used where space is insufficient. Include
THE PEOPLE OF THE STATE OF NEW YORK
as an attachment an executed consent to service of process and corporate resolution, if issuer is a corporation. The consent
to service shall designate the Hawaii Commissioner of Securities as agent. Do not send offering documents unless
TO
requested by the division staff
1. ISSUER. a) Name, address and telephone number of the issuer or issuer to be formed, and principal office, if any, in
this State. b) State
GREETINGS: the name under which the offering will be known.
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on issuer, set the
2. APPLICANT. Name, address and telephone number, if other than the issuer. If same asthe part offorth ''same''
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
3. CORRESPONDENT. Name, address and telephone number of attorney or other correspondent to whom
communications regarding this application should be sent:
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
4. SECURITIES TO BE OFFERED. Check only one:
(
(
(
(
)
)
)
)
Common Stock, $
Preferred Stock.
Units of Limited Partnership Interest.
Other - Please describe:
par value.
Attorney(s) for
Office and P.O. Address
Rev. 7/96
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
039-0953-24
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
5. AMOUNT OF SECURITIES TO BE OFFERED.
Plaintiff(s)
a.
Total Offering
-against- of Shares
Proposed
No.
Share or Unit Price
or Units
Amount
Calendar No.
:
JUDICIAL SUBPOENA
:
Hawaii
No. of Shares
or Units
Amount
:
:
Defendant(s)
:
......................................................
b. Manner of Payment. Will deferred payments be allowed to purchasers?
If yes, please provide details.
Yes
No
THE PEOPLE OF THE STATE OF NEW YORK
TO
6. HAWAII AND FEDERAL STATUS. Set forth the specific provisions of Hawaii's Chapter 485, Hawaii Revised Statutes,
and the specific provisions of Federal statutes and regulations under which this offering is to proceed.
GREETINGS:
Hawaii:
Federal:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
7. in room STATE TRANSACTIONS. day of
OTHER
, on the
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify andthese securities as abe offered or where previous offers of the have occurred and
give evidence will witness in this action on the part or sales
a. List the other states in which
show whether the sales will be under state registration or exemption:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
b. List
result ofthe states, if any, which have refused, by order or otherwise, to authorize sale of these securities, or have
your failure to comply.
revoked or suspended the right to sell these securities, or in which an application for registration or exemption has
been withdrawn. Provide details:
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
8. BROKER-DEALERS OR SALESPERSONS. Name, address and telephone number of broker-dealer registered in Hawaii
(Attorney the sign above and type name below)
and lead broker-dealer, if any. State whether the broker-dealer is a member ofmust NASD.
Attorney(s) for
Where registered issuer salespersons, or persons claiming an exemption, are to be used, set forth their names,
addresses, and telephone numbers, and indicate their registration status or exempt status in Hawaii. Where an
Office and P.O. Address
exemption is claimed, set forth the specific Hawaii provision:
-2-
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
9. PROFESSIONALS INVOLVED. Set forth the names, addresses and telephone numbers of all professionals who have
:
JUDICIAL SUBPOENA
Plaintiff(s)
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
-against:
scope of activities. Include attorneys, accountants, appraisers, engineers, etc.:
:
:
Defendant(s)
:
......................................................
10.
BUSINESS PLAN. Briefly describe the nature of the business to be conducted with the proceeds of this offering:
THE PEOPLE OF THE STATE OF NEW YORK
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
1 1. USE OF PROCEEDS.
Dollar Amount
Percentage
located at
County of
Max
Max
Min
in room
, on the
day of
, 20
, Min
at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Selling Commissions
Other Selling Expenses
Legal, Accounting, Printing
Your failure to comply with this subpoena is punishable as a contempt
and Filing Fees
party on whose behalf this subpoena was issued for a maximum penalty of
the
result of your failureCompensation
to comply.
Offeror/Promoter
Reserves
Witness,
Honorable
Court in remaining funds County, as follows:
day of
The
will be used
of court and will make you liable to
$50 and all damages sustained as a
, one of the Justices of the
, 20
(Attorney must sign above and type name below)
TOTAL
Attorney(s) for
Applicant represents that the minimum amount that must be raised before the project can get underway is $
and that a proceeds escrow under Subchapter 10, Section 16-38-28, Chapter 38, Hawaii
.. if
Administrative Rules, has been established in that amount. (Leave blank if waiver is sought or show ''none
Office and P.O. Address
escrow is not required.)
-3-
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
12. INTEGRATION. Were any securities of the issuer sold within the six months preceding this registration?
:
Yes
Plaintiff(s)
Calendar No.
:
No
JUDICIAL SUBPOENA
If the answer is yes, show how many counting purchasers were involved during the year preceding this registration.
-against:
(Include dates of sale.)
:
:
Defendant(s)
:
......................................................
If sales were made during the past year, provide arguments against integration of the prior sales, if this is desired.
See Subchapter 10, Section 16-38-26, Chapter 38, Hawaii Administrative Rules for elements to consider.
THE PEOPLE OF THE STATE OF NEW YORK
TO
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
GREETINGS:
What is the aggregate offering price? $
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
Court
located at
County of
should any one or more of the items listed under subsection "b"
a . Ans we r "ye s " or "no" a nd provide de ta ils if ''ye s
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
apply to any one or more of the following parties: (i) the issuer, (ii) the predecessors or affiliates of the issuer,
or adjourned date, to testify and give evidence as a witness in thisbeneficial owners of ten percent or more of
action on the part of the
(iii) the issuer's officers, directors, general partners, promoters, or
the Honorable
at
14. ACTIONS AGAINST ISSUER AND AFFILIATED PARTIES. the
any class of its equity securities.
b. Actions:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
(i)
Has filed a registration statement which is the subject of a currently effective stop order damages any
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and allentered byNo
sustained as a
Ye s
state or federal agency within five years prior to the registration of the offering-,
result of your failure to comply.
Witness, Honorable
, one of the Justices of the
Has been convicted, within the ten years preceding the registration, of any felony-, a misdemeanor in
Court in
County,
day of
, involving a false filing with a state-,
Ye s
No
connection with the purchase or sale of a security or20
(ii)
(iii)
(Attorney must sign above and type name below)
Is subject to any state administrative order or judgment, or any federal administrative order or judgment,
including an injunction, entered within the five years preceding the filing of the registration, where a state or
federal banking, insurance, real estate or securities law is the grounds for the order or judgment.
Ye s
No
Attorney(s) for
15. UNDERTAKINGS AND REPRESENTATIONS. The issuer hereby applies for registration of these securities and agrees,
Office and P.O. Address
so long as the registration remains in effect, that it will:
a. Advise the Commissioner of Securities of any changes prior to registration in any of the information filed with
this application and to promptly file any necessary amendments.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
-4-
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
b. Notify the Commissioner of Securities within two business days upon the receipt of any stop order, denial, order
Calendar No.
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 statement or
:
JUDICIAL SUBPOENA
Plaintiff(s)
any other securities of the Issuer or Applicant.
-against-
:
c. Furnish any additional information or documents requested by the Commissioner of Securities where and when
rescission is sought and file and obtain an amendment or registration.
:
d. Keep and maintain all records pertaining to this offering for a period of at least three years from the date of
registration.
:
16. VERIFICATION BY ISSUER.
Defendant(s)
:
......................................................
a. List names and positions of all officers, directors, general partners, or persons holding similar positions with the
issuer.
THE PEOPLE OF THE STATE OF NEW YORK
TO
b. I declare, under penalty of perjury, that I am the
(title or position)
of the issuer and I have read and am familiar with the information in this application and with all materials or
documents to be used in connection with the offering to be made under this application. To the best of my
GREETINGS:
knowledge, information and belief the information contained in this application and in the offering materials is
true, correct, and complete. I have written authorization (available upon written request) from the individuals
WE COMMAND YOU, that this application and make this verification for and on behalf each of you
listed in subparagraph ''a'' to executeall business and excuses being laid aside, you and of the issuer. attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Date
Signature
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Type Name
Subscribed and sworn to before me
Your failure to comply with this
this
day of
subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of Notaryfailure to comply.
your Public, State of
(NOTARIAL SEAL)
1
My Commission expires:
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
17. STATEMENT BY BROKER-DEALER WHERE OFFERING IS DIRECTED TO SUITABLE PERSONS..
(Attorney must sign above and type name below)
The broker-dealer reasonably believes that adequate diligence and review has been applied in connection with this
offering and that broker-dealer will adequately determine the suitability of the offering to each purchaser.
Attorney(s) for
Broker-Dealer
Date
By:
Signature
Office and P.O. Address
Type Name and Title or Position
-5-
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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