Application To Register Securities By Qualification Form. This is a Michigan form and can be use in Blue Sky Secretary Of State.
Tags: Application To Register Securities By Qualification, FIS-0530, Michigan Secretary Of State, Blue Sky
FIS 0530 (3/01) Office of Financial & Insurance Services Division of Securities Application to Register Securities By Qualification This form is to be used for filing by Qualification pursuant to Section 304 and must be used for offerings made pursuant to theRegulation A exemption under the Federal Securities Act of 1933. 1. Issuer Information Name Address (number, street, city, state, zip code) Principal Office in this State 2. Organization Information Form State Date Organized/Incorporated 3. Notices and communications regarding this application may be sent to Name Telephone ( ) Address (number, street, city, state, zip code) 4. Name and address of applicant if different from Issuer Name Address (number, street, city, state, zip code) Indicate Status: Broker - Dealer Selling Shareholder 5. Registration is sought for the following described securities in the amounts indicated Offering Price Total Offering Offering in this State or Proposed Number of Shares Amount Number of Shares Description of Securities Offering Price or Units or Units Amount $ $ Total $ $ Indicate the maximum commission to be charged: % 6. Amount of fee enclosed $ (Fee is $1.00 per $1,000 aggregate sale price, minimum $100, maximum $1,250. Make checks payable to the State of Michigan. Our Web address is http://cis.state.mi.us/ofis This form is issued under Act 265, PA 1964, as amended. You mustOur toll free number is 1-877-999-6442 complete and submit this form if you wish to make an application for registration under Section 304 of the Act. RETURN COMPLETED APPLICATION TO: Division of Securities P.O. Box 30701 Lansing MI 48909-8201 >>>> 27. a) If registration statement has been filed with the Securities and Exchange Commission, please respond to the following, as applicable: Date of Filing with SEC Date filing expected to be declared effective by SEC:Date filing was declared effective with the SEC: b) If not registered with the Securities and Exchange Commission, state basis for exemption. (Include date of submission of exemption request and status) 8. a) List the states in which it is proposed to offer securites for sale. b) List the states, if any, in which the securities are eligible for sale. c) List the states or Canadian provinces or Federal Agencies, if any, which have refused, by order or otherwise, to authorize sale of securities, or have revoked or suspended the right to sell the securities, or in which an application has been withdrawn. 9. As to this issuer, state: a) Prevailing market price per unit, date of quotation, and source thereof, for each class of securites of the issuer, its subsidiaries or parent, outstanding: b) Provide date, price and volume of securities conveyed in last known sale: c) Give number of security holders of each security of the issuer, its subsidiaries or parent:10. Describe any interest in any transaction with the issuer or any significant subsidiary effected within the past three years or proposed to be effected by every partner, managing member, director, and officer of issuer or person occupying a similar status or performing functions. 11. For every partner, managing member, director, and officer of issuer that received or will receive remuneration from a parent, subsidiary, or affiliate of the issuer, file a separate schedule showing the payors name, postion held, remuneration paid the past twelve months, or to be paid in the next twelve months. >>>> 312. Describe any interest in any transaction with the issuer or any significant subsidiary effected within the past three years or proposed to be effected by persons owning 10% or more of outstanding securities not listed in Number 9 above. 13. If the issuer was organized within the past three years, give the following information as to each promoter. Amount of this Issuers Securities Class of Issue He/She Name Home Address Securities Now Owned Intends to Purchase14. a) Describe any interest in any transaction with the issuer or any significant subsidiary effected within the past three years or proposed to be effected by the persons listed in answer to Question 13. b) State the amounts paid within the past three years to each of the persons listed in answer to Question 13. 15. a) If this is a non-issuer distribution in whole or in part, then give the following information as to each person on whose behalf the offering is to be made: Amount of Issuers Amount of Issuers Amount sold during past Securities Now Securities He/She is Home Address Twenty-four Months Name Owned Selling b) With respect to each person listed in (a) above, describe any transaction effected (or which is now proposed to be effected) with the issuer or any significant subsidiary within the past three years. c) State the reasons the persons listed above are making this offering of securities >>>> 416. Submitted herewith as part of this application are the following documents: a) Business Histories (Form FIS 0532) for each officer, director, general partner and managing member. b) Form of subscription agreement. c) Consent to Service of Process. 1)by applicant and also 2)by issuer if applicant is a broker-dealer offering securities for the issuer on an agency basis. If Corporation, also enclosed is a resolution authorizing execution of consent to service of process. d) Copy of any underwriting or selling group agreement pursuant to which the distribution is to be made, or the proposed form of such agreement if the terms have not yet been determined. e) Copy of each management, stock option plan, or other material contract made or to be made otherwise than in the ordinary course of business if it is to be performed in whole or in part at or after the filing of the registration statement or was made within the past three years. f) Copies of prospectus prepared in accordance with Prospectus Instructions (Form FIS 0531). g) One copy of the Registration Statement or any other filing or no action letter on file with the Securities and Exchange Commission. h) Copy of any pamphlet, circular, form letter, advertisement or other sales literature intended as of the effective date to be used in connection with the offering. i) A specimen or copy of the security being registered. j) A copy of issuers articles of incorporation or their substantial equivalents as currently in effect. k) A copy of issuers by-laws or their substantial equivalents as currently in effect. l) A copy of any i