Notice Of Limited Offering Of Securities Form. This is a Virginia form and can be use in Blue Sky Secretary Of State.
Tags: Notice Of Limited Offering Of Securities, VA-1, Virginia Secretary Of State, Blue Sky
FORM VA-1 Part 1 (Rev. 11/96) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING NOTICE OF LIMITED OFFERING OF SECURITIES PURSUANT TO 21 VAC 5-40-100 OF THE SECURITIES ACT RULES The issuer shall file this notice with the Division of Securities and Re tail Franchising not later than 15 days prior to the first sale of securities in this Commonwealth. This notice shall be accompanied by a non-refundable filing fee of $250. 00. This notice shall be deemed filed with the division for purposes of the rule as of the date on which the notice is received by the division. IF ADDITIONAL SPACE IS REQUIRED TO RESPOND COMPLETELY TO ANY ITEM, PLEAS E ATTACH ADDITIONAL SHEETS. 1. Name of issuer:_________________________________________________________________ Address of issuer:______________________________________________________ _________ City______________________State____ Zip_________ Telephone number______ __________ 2. Correspondence to whom communications regarding this notice should be di rected: Name:___________________________________________________________________ _____ Address:________________________________________________________________ _______ City______________________State____ Zip_________ Telephone number________________ 3. Describe, in summary form, the issuers business including but not li mited to the operations being conducted (if the business is not operational, describe when oper ations will begin): 4. Describe in summary form the material risk factors to be considered in p urchasing the securities: 5. Describe, in summary form, material assets owned or leased by the issuer s business and if leased, describe the material terms: 6. Describe, in summary form, pending litigation involving the issuers business or its officers or directors relative to the issuers business: 7. Issuers type of business organization:______________________________ _________________ (corporation, partnership, limited liability company, real estate inves tment trust)8. Year in which the issuer was incorporated or organized:_________________ ________________ 9. State or country in which the issuer was incorporated or organized:_____ ___________________ American LegalNet, Inc. www.USCourtForms.com>>>> 210. Identify the exemption from federal registration on which the issuer is relying in connection with this offering: _________________________________________________________ __________ (SEC Rule 504, Section 4(2) of the Securities Act of 193 3, SEC Rule 147, other (specify))11. List the other jurisdictions in which it is proposed that securities in connection with this offering will be offered or sold:________________________________________________ ____________ 12. Indicate the nature of the issuers securities that are the subject of t his offering:______________ notes ____ debentures____ stocks ____ evidence of indebtedness____ bonds ____ partnership interests____ shares of beneficial interest of a real estate investment trust____ warrants or rights to purchase or subscribe to one of the above____ other securities convertible into one of the above____ 13. Have securities of the same or a similar class as those that are the sub ject of this offering been offered or sold within the six months preceding the beginning of this of fering? Yes ________ No _______ Date of first sale in Virginia:_______________ If "yes", explain briefly: 14. Date of beginning of this offering: ______________________ 15. Aggregate offering price of the securities intended to be sold in this o ffering: $_______________ Number of units offered: ______________________ Price per unit offered: $_____________________ Use of proceeds (be specific) ____________________________________________________ ______________________________________________________________________________ 16. State the aggregate offering price of the securities intended to be sold in Virginia, if different from answer to 15, above: $______________________ 17. On a separate sheet; state the name, home address and position of each o fficer, director, general partner or trustee of the issuer, in the following format: ____________________________________________________________ Name Position ____________________________________________________________ Home Address ____________________________________________________________ City, State, Zip Code American LegalNet, Inc. www.USCourtForms.com>>>> 318. Using a separate sheet if necessary, state the name and home address of each person who is, or will be immediately after completion of this offering, a beneficial owne r of 10% or more of the outstanding class of voting securities of the issuer, in the following f ormat: ____________________________________________________________ Name Position ____________________________________________________________ Address ____________________________________________________________ City, State, Zip Code 19. Using a separate sheet if necessary, identify all persons authorized by the issuer to sell securities of the issuer under this offering, in the following format: ____________________________________________________________ Name ____________________________________________________________ Address _______________________________________(____)________________ City, State, Zip Code Telephone Number Is this person affiliated with the issuer? Yes ______ No _______ If "yes", position: _____________________________________________ Type and value of any remuneration to this person for sale of securities (if "none", so state): ____________________________________________________________ Is this person a broker-dealer or an agent of a broker-dealer?Yes____No_____ 20. Applicants Signature: ____________________________________________________________ Name (please print): __________________________________________ Title: _______________________________________________________ Date of Notice: _______________________________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 4FORM VA-1 Part 2 (Rev. 11/96) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING NOTICE OF LIMITED OFFERING OF SECURITIES PURSUANT TO 21 VAC 5-40-100 OF THE SECURITIES ACT RULES Issuer limited transactional exemption. An issuer must deliver Part 2 of Form VA-1 or a disclosure document cont aining the information required by