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Facing Page Application For Qualification Of The Offer And Sale Of Securities 260.110 - California

Facing Page Application For Qualification Of The Offer And Sale Of Securities Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .
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STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO 260.110 (Register 1993, No. 27) (REV. 8-13) APPLICATION FOR QUALIFICATION OF THE OFFER AND SALE OF SECURITIES UNDER THE CORPORATE SECURITIES LAW OF 1968 (Department of Business Oversight Use Only) Fee Paid $ _______________________ DEPARTMENT OF BUSINESS OVERSIGHT FILE NO___________________________________ (Insert file number of previous filings of Applicant before the Department, if any) Receipt No. _____________________ Effective Date _____________________ FEE:________________________________________ (To be completed by Applicant) Date of Application:__________________________ Application for qualification of the offer and sale of securities under the Corporate Securities Law of 1968, by (check one): Coordination, Section 25111 Notification, Section 25112 Permit, Section 25113(b)(2) Permit (Small Company), Section 25113(b)(2) ( ) Permit, Section 25121 ( ) Negotiating Permit, Section 25102(c) ( ( ( ( ) ) ) ) ( ) Post-Effective ) Amendment ) Number ________ ) To Application ( ) Pre-Effective ) Filed Under ) Section_________ ) Date ___________ This application is for an ( ) open or ( ) limited offering qualification as defined in Section 260.001 of the rules (Check as applicable). 1. Name of Applicant: __________________________________________________________________________________________________ 2. (a) Is applicant a corporation, partnership, trust or other entity?_____________________________________ (b) State of incorporation or jurisdiction under which organized?_____________________________________ (c) If a corporation, is applicant in good standing in the State of its incorporation? (Indicate "yes" or "no") ___________________________________________________________________ (d) Is applicant a registered investment company? (Indicate "yes" or "no") ____________________________ 3. (a) Address of principal executive office of applicant. Number and Street City State ZIP Code _________________________________________________________________________________________ (b) Is the principal location of applicant's books and records at the address of the principal executive office, above? (Indicate "yes" or "no"). If "no", provide address: Number and Street City State ZIP Code _________________________________________________________________________________________ 4. Name and address of person to whom correspondence regarding this application should be addressed ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO 260.110 (Register 1993, No. 27) (REV. 8-13) Page 2 of 4 APPLICATION FOR QUALIFICATION OF THE OFFER AND SALE OF SECURITIES UNDER THE CORPORATE SECURITIES LAW OF 1968 5. (a) Description of Securities (See Instructions on reverse side) (b) Total number of shares or units of each class of securities being qualified in California (e.g., "$20,000") (c) Proposed maximum offering price per unit (e.g., "$10") (d) (e) Proposed maximum Does a public aggregate offering market exist for this class of securities? price for securities being qualified in (indicate "yes" or California (e.g., "no". If "yes" "$200,000") Note: Fee insert CUSIP number) calculated on total of this column _________________ _________________ _________________ _________________ _________________ _________________ _________________ __________ __________ __________ __________ __________ __________ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 6. Consideration to be paid for securities; if cash, state "cash", or if other than cash and the aggregate value is ascribed thereto by the board of directors of the issuer so state (e.g., "Real Property, $100,000," "Assets of a Going Business, $50,000"). 7. There is no adverse order, judgment or decree entered in connection with the offering by any State regulatory authority, any court or the Securities and Exchange Commission, except as follows: (if none, so state.) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO 260.110 (Register 1993, No. 27) (REV. 8-13) Page 3 of 4 APPLICATION FOR QUALIFICATION OF THE OFFER AND SALE OF SECURITIES UNDER THE CORPORATE SECURITIES LAW OF 1968 Instructions: The following instructions must be adhered to with respect to all applications for qualification by permit under Sections 25102(c), 25113 and 25121; by coordination under Section 25111, and notification by Section 25112: Completion of Application. The facing page on the reverse side hereof, must be completed in full and in addition to the facing page, applications must continue by completion of each item of the applicable following forms: Application for qualification by coordination, Form No. 260.111 Application for qualification by notification, Form No. 260.112 Application for permit pursuant to Section 25113, Form No. 260.113 Application for permit pursuant to Section 25121, Form No. 260.121 Application for Negotiating Permit pursuant to Section 25102(c), Form No. 260.113 The numbering sequence in the forms must be adhered to. Any item which is inapplicable should be listed by the number on the form, followed simply by the word "inapplicable." Form of Application. The application should be typewritten or printed in the English language, on one side only of either legal or letter size paper. Signing of Applications. An application for permit pursuant to Section 25113(b)(2) must be reviewed and signed by each member of the board of directors of the small company applicant. Any other application should be signed by an officer or general partner of the applicant; however, it may be signed by another person holding a power of attorney for such purposes from the applicant, and if signed on behalf of the applicant pursuant to such power of attorney, should include as an additional exhibit a copy of said power of attorney or a copy of the corporate resolution authorizing the attorney to act. Item 5--"Public market." A
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