Registration By Notification (Non-Issuer Distribution) Form. This is a Virginia form and can be use in Blue Sky Secretary Of State.
Tags: Registration By Notification (Non-Issuer Distribution), S.A. 5, Virginia Secretary Of State, Blue Sky
S.A.5 (Rev. 11/96) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING REGISTRATION BY NOTIFICATION Non-Issuer Distribution 1. Name and address of issuer:____________________________________________________ ________________________________________________________________________ __ 2. Description of the securities and total amount to be offered ___________________________ ________________________________________________________________________ __ 3. Number of securities to be offered in Virginia______________________________________ 4. Maximum price per security ___________________________________________________ 5. Fee (1/20 of 1% of the maximum offering price of the securities to be o ffered in this state; but such fee shall not be less than $100 nor more than $250.) ________________________________________________________________________ __ 6. Are the offer and sale of the securities hereby directly or indirectly f or the benefit of the issuer? ________________________________________________________________________ __ 7. Have securities of the same class as the security being registered previ ously been registered in Virginia? __________________________________________________________________________ If so, give the date of registration and the name of the person by whom they were registered. ________________________________________________________________________ __ 8. Were the securities being registered originally issued pursuant to an ex emption under 13.1- 514? ______________ If so, state which exemption. ________________________________________________________________________ __ The registrant, after investigation, believes that the facts herein stat ed are true. _____________________________________________ By __________________________________________ Address ______________________________________ Date:______________________ _____________________________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2S.A.5 (Rev. 11/96) INSTRUCTIONS 1. This statement must be accompanied by the fee shown on line 5, payable t o the Treasurer of Virginia. 2. Unless of the registrant is notified to the contrary by the State Corpor ation Commission, the registration becomes effective on 3 P.M. on the second full business day after the statement has been filed in the office of the Commission, if the statement is comp lete and states facts showing eligibility of the securities for registration by notification. If the statement is incomplete, the registration is not effective until after the last amend ment thereto has been filed. 3. Securities issued before January 1, 1957, stand on the same footing as s ecurities issued after that date for the purpose of determining whether they were issued pursua nt to an exemption in 13.1-514. American LegalNet, Inc. www.USCourtForms.com