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OTC Equity Issuer Notification Form. This is a Official Federal Forms form and can be use in FINRA.
Tags: OTC Equity Issuer Notification Form, Official Federal Forms FINRA,
OTC Equity Issuer Notification Form Completion of this form certifies to FINRA™ notification of a corporate action change request for the OTC issuer. Supplemental forms and documentation are required to be submitted along with this notification form. Company Information COMPANY NAME COMPANY ADDRESS _______________________________________________ __________________________________________________________________________________ TELEPHONE FACSIMILE EMAIL _______ WEB SITE ADDRESS _______________________ Contact Information CONTACT NAME CONTACT TITLE NAME OF FIRM (If Applicable) ADDRESS IF DIFFERENT FROM ABOVE TELEPHONE ________________________________________ FACSIMILE EMAIL Company Officers CURRENT OFFICER TITLE OF OFFICER DATE OF APPOINTMENT CURRENT OFFICER TITLE OF OFFICER DATE OF APPOINTMENT CURRENT OFFICER TITLE OF OFFICER DATE OF APPOINTMENT **Required Documentation for Current Officers: For each officer appointment include an executed copy of the board resolutions and meeting minutes duly appointing the officer and giving the officer authority to act on behalf of the company. Security Information Please provide information for other classes of securities that are related to this Issuer. Issue : OTCBB Other-OTC ISSUE SYMBOL(S) CUSIP/CINS NUMBER(S) SECURITY CLASS & DESCRIPTION COUNTRY OR STATE OF INCORPORATION DOMICILE: If of a foreign domicile, does the stock trade on any other foreign exchange? Domestic Foreign Yes No If yes, please provide the following information: NAME OF FOREIGN EXCHANGE CONTACT NAME TELEPHONE EMAIL American LegalNet, Inc. www.FormsWorkFlow.com Transfer Agent Contact Information TRANSFER AGENCY CONTACT NAME ADDRESS TELEPHONE EMAIL DATE OF APPOINTMENT PRIOR TRANSFER AGENT DATE OF TERMINATION PRIOR AGENT REPRESENTATIVE PRIOR AGENCY ADDRESS PRIOR AGENT TELEPHONE PRIOR AGENT FAX PRIOR AGENT EMAIL PRIOR AGENT WEB SITE Transaction Options (Check all that apply and provide the appropriate supplemental forms) Name Change Reverse Merger Merger/Acquisition Transfer Agent Change Holding Company Formation Spin-off Reverse Stock Split Reverse Stock Split followed by Forward Stock Split with a mandatory cash out Forward Stock Split* Choose Method of Payment: Payable upon Surrender of Certificates Mailed Directly to Shareholders Other (please specify) *Issuer Transparency Caution: Issuer acknowledges that by completing a forward stock split resulting in a per share price of less than $.0001, the issuer’s stock will not be quotable in most OTC quotation mediums (including the OTCBB). Issuer further acknowledges that by completing a forward stock split resulting in a per share price of less than $.000001, trades in the issuer’s stock will not be eligible for electronic trade reporting to the FINRA OTC reporting facility. ** Please Note: If the company is effecting or effectuating a Stock Split, you must also fill out a FINRA OTC Equity Name Change / Stock Split Request Form.** Timing All notifications are required to be received by FINRA no later than 10 calendar days prior to the effective date of the corporate action. Processing for the effective time in the market place is determined based upon the satisfactory review of and compliance with all information requested by FINRA. Stock Symbol Change Most corporate actions will require a symbol change. Symbols may neither be reserved for OTCBB or Other-OTC markets, nor can we honor requests for specific issue symbols. Additionally, once a symbol is assigned, FINRA reserves the right to change the symbol. There can be no guarantee that an issuer will retain their symbol indefinitely. Notification of the new stock symbol will be confirmed the day prior to the effective date in the market place. American LegalNet, Inc. www.FormsWorkFlow.com Authorization by Corporate Officer I, __________________________ (print name), hereby certify that the information disclosed in this request is accurate and true. SIGNATURE TITLE DATE Submission of Notification Please return the Issuer Notification along with the appropriate request form and supporting documentation to: FINRA c/o The NASDAQ OMX Group, Inc. Corporate Data Operations Two Corporate Drive 3rd Floor, Suite 300 Shelton, CT 06484 USA Telephone: 203.375.9609 Fax: 203.502.5480 Email: email@example.com American LegalNet, Inc. www.FormsWorkFlow.com