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Notice Of Issuance Of Securities Pursuant To Subdivision (o) Of Section 25102 DBO-25102 O - California

Notice Of Issuance Of Securities Pursuant To Subdivision (o) Of Section 25102 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 ­ 25102(o) (Register 2002, No. 39) (Rev. 08-13) (Department of Business Oversight Use Only) Fee Paid $ Receipt No. NOTICE OF ISSUANCE OF SECURITIES PURSUANT TO SUBDIVISION (o) OF SECTION 25102 OF THE CORPORATIONS CODE DEPARTMENT OF CORPORATIONS FILE No., if any: (Insert File Numbers(s) of Previous Filings Before the Department, If Any) FEE: $ (See Corporations Code Section 25608(y) and Section 25608(e). The fee is based on the current market value of the securities, or in the case of options, the underlying securities.) 1. 2. 3. Name of Issuer: State of Incorporation or Organization: Address of Principal Place of Business: Number and Street 4. [] City State Zip Code The security is issued pursuant to a: (Check One) Purchase Plan or Agreement. Name of Security: Number of Securities: Price Per Security: $ Option Plan or Agreement. Name and Number of Options: Name and Number of the Underlying Securities: Exercise Price Per Security: $ [] _ [] "Flexible" Purchase/Option Plan or Agreement. Name of Security/Option: Number of Securities/Options: Name and Number of the Underlying Securities: Price Per Security: $ Aggregate current market value of securities sought to be sold: $ Date of Notice: Check if Issuer has a consent to service of process on file with the Commissioner 5. 6. () Name of Issuer Authorized Signature on Behalf of Issuer Print Name and Title of Signatory Name, Address and Phone Number of Contact Person: Instructions: Each issuer (other than a California corporation) filing a notice under Section 25102(o) must file a consent to service of process (Form 260.165), unless it already has a consent to service on file with the Commissioner. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT CONSENT TO SERVICE OF PROCESS DBO ­ 260.165 (Revision 2009, No. 39) (Rev. 08-13) TO THE COMMISSIONER OF BUSINESS OVERSIGHT OF THE STATE OF CALIFORNIA KNOW ALL MEN BY THESE PRESENTS: That the undersigned, _____________________________________________________________________ (a corporation, partnership or limited liability company organized under the laws of the State of ________________________), OR ____________________________________________________ (an individual), OR _____________________________________________________ (other entity), hereby irrevocably appoints the Commissioner of Business Oversight of the State of California, or the Commissioner's successor in office, to be the undersigned's attorney to receive service of any lawful process in any noncriminal suit, action or proceeding against the undersigned, or the undersigned's successor, executor, or administrator which arises under the Corporate Securities Law of 1968 or any rule or order thereunder after this consent has been filed, with the same force and validity as if served personally on the undersigned. For the purpose of compliance with the Corporate Securities Law of 1968 of the State of California, notice of the service and a copy of the process should be sent by registered or certified mail to the undersigned at the following address: __________________________________________________________________________________________ (Name and Address) Dated: _________________________, _________. __________________________________ __________________________________ [Insert name of corporation, partnership, limited liability company or other entity] By _____________________________ Title ____________________________ OR [Insert name of individual] ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT CONSENT TO SERVICE OF PROCESS DBO ­ 260.165 (Revision 2009, No. 39) (Rev. 08-13) Page 2 of 2 State of California___________________) County of _________________________) On __________________________ before me, _____________________________________________, (Name of Notary) personally appeared _________________________________________________________________________ (Here, insert Name and Title of the Officer) (who proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature ____________________________ (Seal) Any certificate of acknowledgement taken in another place shall be sufficient in the State of California if it is taken in accordance with the laws of the place where the acknowledgment is made. American LegalNet, Inc. www.FormsWorkFlow.com
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