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Notification Form - Change In Number Of Shares Outstanding Form. This is a Official Federal Forms form and can be use in General Forms NASDAQ.
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The NASDAQ Stock Market®
Notification: Change in the Number
of Shares Outstanding
Important: Please send this Notification to Corporate Data Operations by fax (Toll-free: +1
866 601 9862 Local: +1 203 926 3375) or by email to dividends@nasdaqomx.com.
Pursuant to Rule 5250(e)(1), a company must notify NASDAQ® when there is an aggregate increase or
decrease of any class of securities that exceeds 5 percent of the amount of the securities of the class
outstanding as last reported (in a Form 10-Q or 10-K or their equivalents). This Notification is required
to be filed no later than ten calendar days after this occurrence.
COMPANY NAME
ADDRESS OF PRINCIPAL EXECUTIVE OFFICES
ADDRESS
ADDRESS
PHONE
FAX
EMAIL
Issue listed on:
NASDAQ Global Select Market®
NASDAQ Global Market®
NASDAQ Capital Market®
NASDAQ issue symbol:
CUSIP*/CINS number:
*CUSIP Service Bureau can be reached at +1 212 438 6565 or www.cusip.com.
Title of security:
Number of shares outstanding before the change:
Number of shares outstanding after the change:
Effective date of the change:
Give a brief description of the transaction resulting in the change (such as merger, acquisition,
exchange, distribution, stock split, reverse split, acquisition of stock for treasury, etc.):
Authorization by Corporate Officer
OFFICER’S NAME
TITLE
OFFICER’S SIGNATURE
DATE
1
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Please fax or email the Notification to:
The NASDAQ Stock Market LLC
Corporate Data Operations
Phone: Toll-free: +1 877 308 0523 Local: +1 203 926 3501
Fax:
Toll-free: +1 866 601 9862 Local: +1 203 926 3375
Email: dividends@nasdaqomx.com
©September 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.
2
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