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Application For Qualification Of Securities Previously Sold In Ohio Form. This is a Ohio form and can be use in Blue Sky Secretary Of State.
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Tags: Application For Qualification Of Securities Previously Sold In Ohio, 39, Ohio Secretary Of State, Blue Sky
STATE OF OHIO
Telephone
(614) 644-7381
Department of Commerce
Division of Securities
77 South High Street, Columbus, Ohio 43215-6131
File Number
Form 39
Application for Qualification of Securities Previously Sold in Ohio Without Compliance
With Section 1707.01 to 1707.45, Inclusive, Revised Code of Ohio
(Section 1707.39, Revised Code)
Registrant Must Not fill In.
Division Record --
Date
Checked
By
Notation
Filing Fee ($100.00) Received
Qualification Fee Received
Record Made
Division Order (Application Refused/Granted)
Examination Requested
Prior Registration (Registrant Must Not Fill In.
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
This Registration (Registrant Must Not Fill In.
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
1.
Issuer's Name
2.
Issuer's Address
3.
The issuer is: (State whether individual, partnership, corporation, syndicate, association, etc.)
4.
Date of incorporation or organization
under the laws of
.
State
5.
The charter or articles of association of the issuer now authorize the following securities:
Amount
Description
COM 4542 (Rev. 3/05)
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6.
The issuer now has the following securities sold or subscribed: (Include all classes of stock, bonds,
debentures, promissory notes, or other securities.)
Amount
Amount
7.
Description
Description
The Securities now sought to be qualified, which have been sold or subscribed in OHIO without compliance with
Section 1707.01 to 1707.45, inclusive R.C., are:
A.
B.
Sales Price: (if there were differing prices, attach a separate sheet listing date of sale, number of units, and
sales price for each sale.)
C.
Earliest Date of Sale: (List the earliest date at which (i) a subscription agreement was signed by any
purchaser of securities to qualified or (ii) the date at which the purchaser tendered funds or things of value for
the securities to be qualified.)
D.
Latest Date of Sale: (List the latest date at which (i) either a subscription agreement was signed by any
purchaser of securities to be qualified or (ii) the date at which the purchaser tendered funds or things of value
for the securities to be qualified.)
E.
8.
Type of security to be qualified: (e.g. common stock, limited partnership units, etc.)
Amount of Securities to be qualified in units.
The following are the names and business addresses of all directors, officers, promoters, trustees, partners, or
other managers of the issuer:
Name
9.
Business Address
City
State
Zip
Identify who sold the securities. If other than the issuer, indicate name, address, and Ohio broker-dealer salesman
number for all concerned.
Name
Business Address
City
State
Zip
10.
Indicate amount of commission (dollar amount and percentage) or other remuneration paid to all
individuals connected with this sale:
11.
Submitted herewith is:
(Total fees)
(Check No.)
Payer’s Federal Tax Identification Number
(Needed in case of refund of Qualification Fee)
Two fees are required as follows:
Filing Fee ............................................. $100.00
Qualification Fee (minimum) ................$100.00
(1/5 of 1% of the aggregate price; up to a minimum fee of $2,000.00)
12.
Attached hereto and made part hereof are the following exhibits:
A.
A receipted copy of the issuer’s Articles of Incorporation, and also a copy of By-Laws, and Regulations, if the
issuer is a corporation, or a copy of instruments governing the operation of the issuer and rights of participants
if the issuer is a partnership, trust, syndicate or association.
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B.
A schedule showing (1) the number of units of each type of the issuer’s securities (e.g. common stock, bonds,
preferred stock, etc.) held by each director, promoter, trustee, partner, or other executive manager or officer
(2) a detailed description of what was paid to the issuer in cash, real estate, patents, services or other items of
value in the purchase of such securities by each of such persons.
C.
A schedule showing (1) the names and addresses of all persons who purchased securities sold in violation of
Section 1707.01 to 1707.45, inclusive, R.C., now sought to be qualified, and (2) a detailed description of what
was paid to the issuer in cash, real estate, patents, services or other items of value in the purchase of such
security by each of such person.
D.
A copy of each subscription agreement signed by the purchasers.
E.
Copies of all contracts or other instruments pertaining to the sale of issuer’s securities and used in connection
with such sale.
F.
Copies of any letters, literature, or prospectuses used in connection with the sale of issuer’s securities.
G.
Provide balance sheet and income statements for the prior three years for the entity whose securities are to be
qualified.
Supply either:
(1)
Audited statements with auditor’s letter, or
(2)
An affidavit of the Chief Executive Officer of the entity whose securities are to be
qualified hereunder. Affidavit shall be made under oath or affirmation of the officer
attesting that, to his best knowledge and belief, the financial statement and supporting
schedules are true and correct.
(Name of Issuer or Applicant)
X Signed By:
(Officer, Partner, Dealer or Applicant)
COUNTY OF
STATE OF
being first duly sworn, deposes and says that he is
that he
(Officer, Partner, Dealer or Applicant)
has read the foregoing applications; that he has knowledge of the facts, and that the facts stated are true, as he verily believes.
X Signed By:
(Officer, Partner, Dealer or Applicant)
Sworn to and subscribed before me this
day of
(Month, Year)
Notary Public
County
Name, address, and telephone number or correspondence to whom communications regarding this application
may be sent:
The Statement of Non-Prejudice to be signed by the original purchasers will be
forwarded upon receipt of this application with appropriate fees attached.
Address all communications and make all checks payable to:
Ohio Division of Securities, 77 South High Street, Columbus, Ohio 43215-6131
614-644-7381
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