Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
OTC Equity Name Change-Stock Split Request Form. This is a Official Federal Forms form and can be use in FINRA.
Tags: OTC Equity Name Change-Stock Split Request, Official Federal Forms FINRA,
OTC Equity Name Change / Stock Split Request Completion of this form certifies to FINRA™ notification of a corporate name change and/or provides FINRA™ notification of a forward stock split or a reverse stock split for an OTC Equity issuer. Transaction Information Name Change CURRENT COMPANY NAME CURRENT ISSUE SYMBOL(S) NEW COMPANY NAME (if applicable) CUSIP/CINS NUMBER(S): CURRENT NEW (if applicable) ANTICIPATED FILING DATE OF THE CHARTER AMENDMENT FOR NAME CHANGE : LEGAL EFFECTIVE DATE OF CHARTER AMENDMENT FOR NAME CHANGE: Yes DID THE SECRETARY OF STATE ACCEPT THE CHARTER AMENDMENT? No If no, please specify the reason the charter amendment was declined by the SOS? DATE OF APPROVAL FOR THE ACTION BY THE BOARD OF DIRECTORS: ________________________________________ BASED ON THE STATE OF INCORPORATION IS SHAREHOLDER APPROVAL REQUIRED FOR THE NAME CHANGE TO BECOME LEGALLY EFFECTIVE? Yes No IF YES, DATE OF APPROVAL FOR THE ACTION BY SHAREHOLDERS (If Applicable): IF NO, PLEASE PROVIDE EXPLANATION OF STATE LAW: Stock Split CURRENT COMPANY NAME TYPE OF SPLIT: Forward CURRENT ISSUE SYMBOL(S) Reverse AMOUNT OF STOCK SPLIT RATIO: PLEASE CONFIRM THE PAYMENT METHOD OF THE FORWARD STOCK SPLIT (If Applicable): PAYABLE UPON SURRENDER OF OLD CERTIFICATES (REQUIRES A NEW CUSIP NUMBER) NEW SHARES ARE BEING MAILED DIRECTLY TO SHAREHOLDERS (REQUIRES RECORD DATE AND PAYABLE DATE) CUSIP/CINS NUMBER(S): CURRENT NEW PRE-SPLIT TOTAL SHARES OUTSTANDING: AS OF DATE: POST-SPLIT TOTAL SHARES OUTSTANDING: AS OF DATE: METHOD OF SETTLING FRACTIONAL SHARES (If Applicable): Explanation of any conditions which must be met for the transaction to become effective: American LegalNet, Inc. www.FormsWorkFlow.com PLEASE CONFIRM IF THE FOLLOWING ACTION(S) IS(ARE) REQUIRED FOR THE STOCK SPLIT TO BECOME LEGALLY EFFECTIVE: 1. FILING A CHARTER AMENDMENT WITH THE SECRETARY OF STATE (SOS) OR OTHER REGULATORY AUTHORITY Yes No IF YES, ANTICIPATED FILING DATE OF THE CHARTER AMENDMENT FOR STOCK SPLIT (If Applicable): IF NO, PLEASE PROVIDE EXPLANATION OF STATE LAW: CONFIRM THE DATE THAT THE CHARTER AMENDMENT WAS FILED WITH THE SECRETARY OF STATE (If Applicable): DID THE SECRETARY OF STATE ACCEPT THE CHARTER AMENDMENT? (If Applicable) Yes No If no, please specify the reason the charter amendment was declined by the SOS? 2.BOARD OF DIRECTORS RESOLUTION Yes No IF YES , PLEASE PROVIDE THE DATE OF APPROVAL/AUTHORIZATION: IF NO, PLEASE PROVIDE EXPLANATION OF STATE LAW: 3. SHAREHOLDER RESOLUTION (IF REQUIRED BASED ON THE STATE OF INCORPORATION) Yes No IF YES , PLEASE PROVIDE THE DATE OF APPROVAL/AUTHORIZATION: IF NO, PLEASE PROVIDE EXPLANATION OF STATE LAW: **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 media (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. Required Documentation Issuer Notification Form Executed & Notarized corporate confirmation of the Shareholders Consent (e.g., board resolutions, corporate officer certificate, etc.) Cover letter providing a full corporate history for this corporation (Start on the original date of incorporation and include all the corporate changes that have occurred until present day, including, but not limited to, changes of control, reverse mergers, name changes, etc.) Transfer Agent Verification Form Copy of the Certificate of Merger, Amendment to the Articles of Incorporation or other Documents filed with the State of Incorporation Prior Transfer Agent Notification (If Required) Copy of original issuer certified articles of incorporation CUSIP confirmation from the CUSIP Service Bureau (212-438-6565 or www.cusip.com) - (if applicable) An opinion letter from attorney licensed in the state upon which opining that the entity in question is the same corporate entity and the transaction is otherwise legal*** **If there is not a requirement for a filing with the Secretary of State or approval by shareholders or directors, the company needs to confirm this in writing.** ***The requirement to provide a legal opinion letter applies only to Corporate Actions in which there are multiple entities involved in the transaction (e.g., merger or acquisition).*** 2 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 Name Change Request Please return the Issuer Notification along with the appropriate request form, 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 3 American LegalNet, Inc. www.FormsWorkFlow.com