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Dual Listing Application Form. This is a Official Federal Forms form and can be use in Additional Listing Applications NASDAQ.
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The NASDAQ Stock Market®
Dual Listing Application
(This listing application should be executed and submitted by an issuer currently listed on a national
securities exchange and seeking dual listing on The NASDAQ Stock Market.)
PART I: Company Information
COMPANY NAME
ADDRESS OF PRINCIPAL EXECUTIVE OFFICES
STATE OF INCORPORATION
DATE OF INCORPORATION
Market Choice: An issuer seeking to list on either the Global Select Market or the Global Market will be
approved for the market tier with the highest listing standards that the company meets.
NASDAQ Global Select Market®
NASDAQ Global Market®
NASDAQ Capital Market®
Application - Primary Contact
Please provide a primary contact for the purposes of processing this Listing Application.
NAME
FIRM
ADDRESS
PHONE
FAX
EMAIL
Company Contact
If the primary contact supplied above is someone other than an employee of the company, please provide a
contact at the company.
NAME
ADDRESS
PHONE
EMAIL
PART II: Security Information
Description of issue(s) to be listed (include current symbol(s), par or stated value, warrant expiration date
and exercise price, ratio for American Depositary Shares to underlying shares, and other relevant
information):
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PART III: Board Member Information
Please provide the following information regarding any individuals that have either joined or left the
applicant's board since the date of the applicant’s last proxy statement. Attach an additional sheet, if
necessary.
New Board Members
Provide each board member’s full name (first, middle and last).
NAME
DATE SERVICE COMMENCED
PRIMARY EMPLOYER AND POSITION (IF APPLICABLE)
DEEMED INDEPENDENT UNDER NASDAQ’S RULES
Yes
No
BOARD COMMITTEE PARTICIPATION (IF ANY)
Audit Committee
Compensation Committee
Nominations Committee
Other (please specify)
Departing Board Members
NAME
DATE SERVICE ENDED
Board Composition and Committees
Submit a completed Corporate Governance Certification Form, a copy of which can be found in the NASDAQ
OMX Listing Center. Please note that this form need not necessarily accompany the company’s initial
submission.
PART IV: Additional Information and Documentation
The fact that an applicant may meet NASDAQ’s numerical guidelines does not necessarily mean that its
application will be approved. In connection with the review of any application, and as set forth in the
NASDAQ Listing Rules, NASDAQ reserves the right to request additional information or documentation,
public or non-public, deemed necessary to make a determination regarding a security’s qualification for
initial inclusion, including but not limited to, any material provided to or received from the Securities and
Exchange Commission or other regulatory authority.
Please provide the following information in a separate attachment to this application.
Regulatory Proceedings/Litigation
Provide a detailed description of any ongoing, undisclosed investigation involving either the Company or any
of its executive officers or directors being conducted by the SEC, FINRA, the CFTC, the Department of
Justice or any other federal or state criminal authority.
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Affirmation - Please sign and date the application.
I,
, as
NAME OF INDIVIDUAL
of
TITLE
COMPANY NAME
hereby certify, to the best of my knowledge and belief, that the information contained in the
application is true and correct, as of the date below, and will notify NASDAQ promptly of any material
changes.
Signature of Company Officer
SIGNATURE
DATE
Submission
Send the Application and supporting documentation to:
The NASDAQ Stock Market LLC
Listing Qualifications
9600 Blackwell Road
Rockville, MD 20850
©April 2011, The NASDAQ OMX Group, Inc. All rights reserved. The NASDAQ Stock Market, NASDAQ, The NASDAQ Global Select
Market, The NASDAQ Global Market and The NASDAQ Capital Market are registered trademarks of The NASDAQ OMX Group, Inc.
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