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Application For Registration Of Viatical Investments RQV - Colorado
| Application For Registration Of Viatical Investments Form. This is a Colorado form and can be used in General Blue Sky Secretary Of State . |
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FORM RQV Colorado Division of Securities Colorado File No.: RQV 1580 Lincoln Street, Suite 420 Denver, CO 80203 APPLICATION FOR REGISTRATION OF VIATICAL INVESTMENTS Pursuant to the requirements of section 11-51-304, C.R.S., Rule 51-3.2 a nd the Interpretive Order dated May 12, 2003, application is made for registration of the described securities a nd the following information is submitted: 1. NAME AND ADDRESS OF VIATICAL ISSUER:2. TITLE OR DESCRIPTION OF VIATICAL INVESTMENT: 3. AMOUNT TO BE REGISTERED: Offering Price Amount of Viatical Investment Total Investment Amount $ $ 4. Is this an initial Colorado registration or an amendment to increase the size of a previously registered Colorado offering? INITIAL AMENDMENT 5. NAME AND ADDRESS OF UNDERWRITER OR PRINCIPAL BROKER-DEALER (IF ANY): 6. Will these Viatical Investments be sold by an individual acting as a sales representative for the issuer? YES NO 7. NAME, ADDRESS AND TELEPHONE NUMBER OF ATTORNEY, AGENT OR CORRESPONDENT: 8. Attach Appointment and Consent to Service of Process (Forms U-2 & U-2a) ; or, if such forms have previously been filed with this office, state the date filed and the documents whic h they accompanied. 9. FILING FEE: $ (payable to Colorado State Treasurer) Signature of Applicant Type the Name and Title of Applicant (Rev. 5/2003) American LegalNet, Inc. www.USCourtForms.com
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