Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Sale Of Securities Pursuant To The Missouri Accredited Investor Exemption Form. This is a Missouri form and can be use in Blue Sky Secretary Of State.
Tags: Notice Of Sale Of Securities Pursuant To The Missouri Accredited Investor Exemption, AI, Missouri Secretary Of State, Blue Sky
Robin Carnahan Secretary of State State of Missouri Securities Division • 600 W. Main • PO Box 1276 Jefferson City, MO 65102 Notice of Sale of Securities Pursuant to the Missouri Accredited Investor Exemption 1. Issuer Name: Address: Phone Number: 2. Form of Organization (Check One) ( ) Corporation ( ) Unincorporated Association ( ) Limited Partnership ( ( ) Limited Liability Company ) Other (Specify) Issuer’s state of Incorporation or jurisdiction or organization Date of Incorporation or Organization 3. Officers and Directors (or persons acting in a similar capacity) Names, Addresses and Phone Numbers: 4. This Offering: Description of Security Debt Equity (common or preferred) Convertible Security Partnership Interests Other (Specify) Price per security Number of securities to be offered Aggregate dollar amount FORM AI (03-06) American LegalNet, Inc. www.FormsWorkflow.com 5. Description of business: 6. Name of Broker-Dealer who has solicited or intends to solicit purchasers in this state. Business Address By filing this Notice of Transaction, the issuer of these securities hereby represents that: (1) (2) (3) Sales of securities shall be made only to accredited investors as defined in 17 CFR 230.501(a). The issuer is not an issuer in the development stage that either has no specific business plan or purpose or has indicated that its business plan is to engage in a merger or acquisition with an unidentified company or companies, or other entity or person. The issuer reasonably believes that all purchasers are purchasing for investment and not with the view to or for sale in connection with a distribution of the security. Any resale of a security sold in reliance on this exemption within 12 months of sale, except a resale to an accredited investor or pursuant to a registration statement effective under applicable state securities law, shall be presumed to be with a view to distribution and not for investment. Securities issued under this exemption may only be resold pursuant to registration or an exemption under applicable state securities law. FORM AI (03-06) American LegalNet, Inc. www.FormsWorkflow.com The undersigned represents that the issuer is familiar with the conditions that must be satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is filed and understands that the issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied. The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. Issuer (Print or Type) Signature Name (Print or Type) Date Title (Print or Type) Note: Completion of this form does not relieve the filer of the obligation to ascertain and comply with any additional state requirements that may apply, such as consent to service of process, payment of requisite fees, and filing of copies of any general announcement of the proposed offering. FORM AI (03-06) American LegalNet, Inc. www.FormsWorkflow.com