Accredited Investor Exemption
Accredited Investor Exemption Form. This is a North Dakota form and can be use in Blue Sky Secretary Of State.
Tags: Accredited Investor Exemption, AIE, North Dakota Secretary Of State, Blue Sky
FORM AIE Securities Department 600 E Boulevard Ave Dept 414 Bismarck ND 58505 (701) 328-2910 www.ndsecurities.com ACCREDITED INVESTOR EXEMPTION NORTH DAKOTA SECURITIES DEPARTMENT SFN 52009 (7-2011) UNIFORM NOTICE OF TRANSACTION NOTICE OF SALE OF SECURITIES PURSUANT TO ACCREDITED INVESTOR EXEMPTION, SECTION 10-04-06, N.D.C.C. 1. ISSUER: Name: Telephone Number: Address: City: State: Zip Code: 2. FORM OF ORGANIZATION (Check One) Corporation Unincorporated Association Limited Liability Company Limited Partnership Other (Specify) 3. OFFICERS AND DIRECTORS (or persons acting in a similar capacity) 4. THIS OFFERING: Description of Security Debt (Specify) Common Stock Preferred Stock Convertible Security Partnership Interests Limited Liability Interests Other (Specify) 5. DESCRIPTION OF BUSINESS: Price per Security Number of Securities to be Offered Aggregate Dollar Amount SFN 52009 (7-2011) Page 2 of 2 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) Sales of securities shall be made only to accredited investors as defined in 17 CFR 230.501(a). (2) 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. (3) 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. 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. Include with the notice form a Consent to Service of Process (Form U-2); the general announcement, if applicable; and a filing fee of $150. 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: Date: Name: (Print or Type) Title: (Print or Type)