Registration By Notification (Original Issue) Form. This is a Virginia form and can be use in Blue Sky Secretary Of State.
Tags: Registration By Notification (Original Issue), S.A. 4, Virginia Secretary Of State, Blue Sky
S.A. 4 (Rev. 11/96) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING _____________ REGISTRATION BY NOTIFICATION Original Issue 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 offered in this state; but such fee shall not be less than $100 nor more than $250.) _____________ __________________ 6. Date and place of incorporation or organization ________________________________________________________________________ ______ 7. How long has the issuer (including any predecessor by merger, consolida tion or acquisition of assets) been in continuous operation? _________________________________ _______________ 8. Has there been any default by the issuer within its past three fiscal years in payment of principal, interest or dividends on any of its debt obligations or preferred stock? ______________________9. If the securities being registered include common stock and are register ed under 13.1-508 A 1 (A), answer the following: a. Value of the issuers assets after deduction of depreciation and othe r reserves; and the basis of such value (cost, etc.) _____________________________________ __________ b. What is the net worth of the issuer? __________________________________________ 10. If the securities being registered include common stock and are register ed under 13.1-508 A 1 (B), answer the following: a. Net earnings of issuer applicable to all common stock during each of the past three fiscal years: (1) ____________________ (2) ____________________ (3) ____________________ Average _________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 b. If common stock of issuer is outstanding on date of this statement: (1) Number of shares of all classes of common stock ________________________________________________________________ (2) Maximum public offering price per share within past thirty days or maxim um market price per share within past thirty days, whichever is higher; but if there is neither a readily determinable market price nor a public offering pri ce, the book value per share as shown by a balance sheet dated within ninety day s. State which. ________________________________________________________________ (3) Divide average net earnings shown in 10 (a) by value of outstanding co mmon stock (number of shares in answer 10 (b) (1) multiplied by per shar e value in answer 10 (b) (2)) __________________________________% (4) If no common stock of issuer is outstanding on date of this statement, d ivide average net earnings shown in 10 (a) by aggregate offering price of su ch securities offered for sale (number of shares in answer 2 multiplied by maximum price per security in answer 4) __________________________________% CERTIFICATE The undersigned registrant certifies that he has investigated the matters herein referred to and that he believes the facts herein stated to be true and all accounting d eterminations to have been made in accordance with generally accepted accounting practices. __________________________________________ By _______________________________________ DATE: Address ___________________________________ __________________________________________ ________________________________________________________________________ _____________ INSTRUCTIONS 1. This form must be accompanied by the three (3) most current Annual Fin ancial Statements of the issuer and/or its predecessor, a proposed prospectus and the applicable fee payable to Treasurer of Virginia. 2. Unless the registrant is notified to the contrary by the State Corporati on Commission, the registration becomes effective at 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 complete and states facts showing eligibility of the securities for registration by notification. If the statement is incomplete, the registration is not effective until the last amendment thereto has been filed. American LegalNet, Inc. www.USCourtForms.com