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Application For License For New Hampshire Issuer-Dealer Form. This is a New Hampshire form and can be use in Blue Sky Secretary Of State.
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Tags: Application For License For New Hampshire Issuer-Dealer, D-1, New Hampshire Secretary Of State, Blue Sky
Form D-1
State of New Hampshire
Department of State
Bureau of Securities Regulation
No.
Rec'd
App'd
Fee
Granted
Application for License for New Hampshire Issuer-Dealer
The undersigned hereby applies for a license authorizing it to sell its securities in this state under the New
Hampshire Blue Sky Law and makes the following statement:
1. Name of applicant
2. Address of applicant
3. Telephone No.
4. Date of incorporation or organization, and place:
5. Type of Organization:
Corporation
Partnership/LLP
6. Are you actually engaged in business in this state?
LLC
Proprietorship
Other
Yes
7. Give the names, residences, business addresses, capacity and title of all persons interested in the business as
principals, officers, directors, managers or managing agents.
Name
Residence
Business Address
Capacity and Title
8. In what other states have you ever applied for a securities license?
9. In what other state are you licensed or registered?
10. State briefly the general plan and character of the business of applicant, specifying the nature of property in
which it is proposed to deal, and the method of transacting business, whether by solicitation, advertisement,
correspondence or otherwise.
11. Type and amount of securities for which qualification is requested
12. Date and month of end of fiscal year
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There are attached hereto and made a part hereof:
(a) Copy of charter, articles of incorporation, or limited liability company, or limited partnership agreement certified by proper
state official.
(b) Copy of by-laws certified by Clerk of the Corporation.
(c) Certified copies of Profit and Loss Statement and Balance Sheet as of last December 31, or close of fiscal year.
(d) Pro-forma Balance Sheet (if new entity with no operating history).
(e) Copy of offering memorandum or prospectus.
(f) Three references as to the business repute and character of applicant, from unaffiliated persons, including names,
addresses, and telephone numbers.
(g) Form D-1, properly executed, by each of the persons signing below.
(h) There is enclosed herewith the fee due on filing this application.
(Corporate seal if incorporated)
THIS APPLICATION MUST BE SIGNED BY ALL THE OFFICERS, PRINCIPALS, DIRECTORS, MANAGERS, MANAGING
AGENTS, OR PARTNERS OF THE CORPORATION OR OTHER LEGAL ENTITY.
4.
1.
Signature
Date
DOB
Signature
SS#
DOB
2.
Date
SS#
5.
Signature
Date
DOB
Signature
SS#
DOB
3.
Date
SS#
6.
Signature
Date
DOB
SS#
Signature
DOB
Date
SS#
STATE OF
COUNTY OF
Subscribed and sworn to before me this _______ day of ________________, ______
Notary Public
My commission expires
Sec. Form D-1 9/2008
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