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Transfer Agent Verification Form. This is a Official Federal Forms form and can be use in FINRA.
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Transfer Agent Verification Form Completion of this form certifies to FINRATM notification of a corporate action (e.g., a name change, stock split, and/or spin-off) for an OTC issuer. This form is required to be filled out and submitted by the transfer agent only. Transfer Agency: *Required Field AGENCY NAME:* Yes IS TRANSFER AGENCY A SEC REGISTERED AGENT?* No, please confirm where registered: AGENCY ADDRESS:* AGENCY REPRESENTATIVE:* TELEPHONE:* TITLE:* FACSIMILE: EMAIL:* WEBSITE:* WHERE DID THE AGENT RECEIVE NOTIFICATION FROM? * OTC Issue Requiring Change: ISSUER LEGAL COUNSEL OTHER *Required Field COMPANY NAME : * ADDRESS: * CITY:* ZIP/POSTAL CODE:* STATE/PROVINCE:* COUNTRY OF INCORPORATION:* IF US, STATE OF INCORPORATION: DATE OF INCORPORATION OR RE-INCORPORATION:*: CONTACT NAME:* TELEPHONE:* TITLE:* FACSIMILE: Appointment Verification: EMAIL:* *Required Field DATE OF APPOINTMENT AS TRANSFER AGENT:* If date of appointment is within last six months, please provide the following information: PRIOR TRANSFER AGENT: DATE RECORDS WERE TRANSFERRED AND RECEIVED FROM PRIOR AGENT: TRANSFER AGENT VERIFICATION FORM REV. (03/09) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Transaction Options (please fill out all that apply): Name Change: NEW COMPANY NAME: CUSIP/CINS NUMBER(S): CURRENT: NEW: ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * * Stock Split: FORWARD SPLIT PAYABLE UPON SURRENDER OF OLD CERTIFICATES CUSIP/CINS NUMBER(S): CURRENT: NEW: STOCK SPLIT RATIO: FORWARD SPLIT - NEW SHARES ALLOCATED/MAILED DIRECTLY TO SHAREHOLDERS CUSIP/CINS NUMBER(S): CURRENT: NEW: RECORD DATE: PAYABLE DATE: STOCK SPLIT RATIO: REVERSE SPLIT CUSIP/CINS NUMBER(S): CURRENT: NEW: RECORD DATE: PAYABLE DATE: STOCK SPLIT RATIO: The following information is required for all stock splits: PRE-SPLIT TOTAL SHARES OUTSTANDING: AS OF DATE: POST-SPLIT TOTAL SHARES OUTSTANDING: AS OF DATE: METHOD OF SETTLING FRACTIONAL SHARES: ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * * Any conditions which must be met for the transaction to become effective: Spin-Off: SPIN-OFF COMPANY NAME: PARENT ENTITY: CUSIP/CINS NUMBER(S): Spin-Off Company: Parent Entity: RELATIONSHIP BETWEEN SPIN-OFF AND PARENT ENTITY: ANTICIPATED EFFECTIVE DATE FOR CORPORATE ACTION: * * ** NOTE: Processing of Corporate Action prior to announcement on the OTCBB or OTC Daily List may result in subsequent clearance and settlement issues. TRANSFER AGENT VERIFICATION FORM REV. (03/09) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Other (please specify): Stock Certificate Verification: *Required Field ARE THE EXISTING SHARES DEPOSITORY ELIGIBLE AND HELD AT DTC?* Yes No CAN DTC HOLD THE NEW CERTIFICATES IN NOMINEE NAME? * Yes No IS THE SURRENDER OF CERTIFICATES MANDATORY?* Yes, please specify effective date: No WHEN WILL NEW INVENTORY BE AVAILABLE?* ARE THERE ANY RESTRICTIONS ON THE NEW SHARES?* Yes, please specify (i.e., 144, legend, etc.): No Authorization by Transfer Agent Representative: *Required Field , hereby certify that all requirements by the Transfer Agent have been I *, satisfied to process the transaction and that all the information disclosed in this request is accurate and true. SIGNATURE:* DATE:* Submission of Transfer Agent Notification: FINRA Operations, 5th Floor 9509 Key West Avenue Rockville, MD 20850 Telephone: 1.866.776.0800 Fax: 202.689.3533 Email: OTCcorpactions@finra.org E-mail Submit Print Form TRANSFER AGENT VERIFICATION FORM REV. (03/09) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com