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Application For License For New Hampshire Issuer-Dealer D - New Hampshire

Application For License For New Hampshire Issuer-Dealer Form. This is a New Hampshire form and can be used in Securities Secretary Of State .
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New Hampshire Form D No. ____________________________ STATE OF NEW HAMPSHIRE Recd __________________________ DEPARTMENT OF STATE Appd __________________________ BUREAU OF SECURITIES REGULATION Fee ____________________________ Granted ________________________ Application for License for New Hampshire Issuer-DealerTo the Secretary of State The undersigned hereby applies for a license authorizing it to sell its securitiesin this state under the New Hampshire Blue Sky Law and makes the following statement:1. Name of applicant 2. Address of applicant 3. Telephone No. 4. Date of incorporation or organization, and place: 5. (a) Type of Organization: Corporation Partnership/LLP6. Are you actually engaged in business in this state?LLCProprietorshipOther7. Give the names, residences, business addresses, capacity and title of all personsinterested in the business as principals, officers, directors, managers or managingagents. Name Residence Business Address Capacity and Title8. In what other states have you ever applied for a securities license?9. In what other state are you licensed or registered? 10.State briefly the general plan and character of the business of applicant,specifying the nature of property in which it is proposed to deal,and the method oftransacting business, whether by solicitation, advertisement, correspondence orotherwise. <<<<<<<<<********>>>>>>>>>>>>> 2 11.Type and amount of securities for which qualification is requested There are attached hereto and made a part hereof: (a) Copy of charter, articles of incorporation, or limited liability company, or limited partnership agreement certified by proper state official. (b) Copy of by-laws certified by Clerk of the Corporation (c) Certified copies of Profit and Loss Statement and Balance Sheet as of last December 31, or close of fiscal year. (d) Pro-forma Balance Sheet (if new entity with no operating history). (e) Copy of offering memorandum or prospectus. (f) Three references as to the business repute and character of applicant, from unaffiliated persons, including names, addresses, and telephone numbers. (g) Form D-1, properly executed, by each of the persons signing below. (h) There is enclosed herewith the fee due on filing this application. (Corporate seal if incorporated)THIS APPLICATION MUST BE SIGNED BY ALL THE OFFICERS, PRINCIPALS, DIRECTORS, MANAGERS, MANAGINGAGENTS, OR PARTNERS OF THE CORPORATION OR OTHER LEGAL ENTITY.(Sign here) 1.___________________________________ 5._________________________________________ Date Date DOB SS# DOB SS# 2._____________________________________ 6._________________________________________ Date Date DOB SS# DOB SS# 3._____________________________________ 7_________________________________________ Date Date DOB SS# DOB SS# 4._____________________________________ 8.________________________________________ Date Date DOB SS# DOB SS# STATE OF COUNTY OF Subscribed and sworn to before me this day of , _________________________________________ Notary Public My commission expires
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