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Midwest Reginal Review Application Form. This is a Missouri form and can be use in Blue Sky Secretary Of State.
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Tags: Midwest Reginal Review Application, SR-3, Missouri Secretary Of State, Blue Sky
Robin Carnahan
Secretary of
State of Missouri
State
Securities Division • 600 W. Main • PO Box 1276
Jefferson City, MO 65102
MIDWEST REGIONAL REVIEW APPLICATION
1.
Name of Issuer:
Fax number:
2.
E-Mail Address:
The issuer (''applicant'') is filing for Coordinated Midwest Regional Review in the following states
(please check all that apply; at least two must be checked):
Illinois
Indiana
Iowa
Kansas
3.
North Dakota
South Dakota
Wisconsin
Minnesota
Michigan
Missouri
Nebraska
The applicant shall send to each state, a copy of this Application, accompanied by the exhibits (See
Appendix A) and the fees required by that state (see Appendix B). These filings shall be made
simultaneously in each state as checked in Item 2 above. The documents filed in each state shall be
identical. (Note: Subsequent to the initial filing for Midwest Regional Review, the issuer may file a new
application in at least two of the remaining participating states, but will then be subject to a new
coordinated review.)
Type of filing (please check one):
Small Company Offering Registration (SCOR Form U-7)
Question/Answer Form Model A under Regulation A
Offering Circular Model B under Regulation A Form 1-A (Traditional Disclosure)
4.
Undertakings of Applicant:
The applicant agrees that it will file simultaneously in each state checked above.
The applicant waives automatic effectiveness in each state checked above.
The applicant agrees to resolve outstanding comments through the lead state and agrees to provide the
lead state with a copy of the amended offering document marked to show changes. (Note: State-specific
comments must be resolved with the state to which the comment applies.)
The applicant understands that the securities to be registered must be sold by an agent that is either
registered or exempt from registration in the subject state. The applicant agrees not to allow sales by
agents that have not been registered or are not exempt in the state in which they are selling.
The applicant agrees to file all final documents with each state.
Applicant Representative:
Signature & Date
Print Name & Title
FORM SR-3 (01-05)
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