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Application To Offer Or Sell Securities 8 - Georgia
| Application To Offer Or Sell Securities Form. This is a Georgia form and can be used in Securities And Business Regulation Blue Sky Secretary Of State . |
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SECURITIES AND BUSINESS REGULATION 237 Coliseum Drive Macon, Georgia 31217-3858 (478) 207-2440 http://www.sos.ga.gov/securities/ BRIAN P. KEMP Commissioner of Securities APPLICATION TO OFFER OR SELL SECURITIES FORM 8 Georgia Uniform Securities Act of 2008, as amended O.C.G.A. §§ 10-5-21, 10-5-22 and 10-5-23 Name of Issuer: A. Types of Filings and Fees Check One Type Registration by Qualification - O.C.G.A. §10-5-23 Registration by Coordination - O.C.G.A. §10-5-22 Small Issue Registrant - O.C.G.A. §10-5-23 Uniform Limited Offering Exemption - O.C.G.A. §10-5-21(c) Renewals - O.C.G.A. §§10-5-22; 10-5-23 Required Fee 1/20 of 1% aggregate offering (Minimum $250) $250 (Nonrefundable) (Use Form U-1) 1/20 of 1% aggregate offering (Minimum $250) $250 (Nonrefundable) (Use Form D) $100 (Nonrefundable) Amount Enclosed Nonprofit Issuer Registration - O.C.G.A. §10-5-23 Nonprofit Issuer Renewal - O.C.G.A. §10-5-23 None Required None Required (Please make all checks payable to: COMMISSIONER OF SECURITIES, STATE OF GEORGIA) B. General Information 1. Name & Address of Issuer: Name Phone Number Address City State Zip 2. Name, Address and Phone Number of Correspondent to whom notices and communications regarding this application may be sent: Name Phone Number Address City State Zip 3. Name and Address of the Applicant: Name Phone Number Address City State Zip 4. Registration or acceptance for filing is sought for the following described securities: Total Offering Description of Securities Offering Price or Proposed Offering Price Number Of Shares or Units Amount Offering in Georgia Number of Shares or Units Amount Form 8 Rev. 2/2011 American LegalNet, Inc. www.FormsWorkFlow.com 1 5. Type Organization (Check One Type and include all requested information.) Corporation Date Incorporated /Organized Place Incorporated/Organized (If Limited Partnership, Include County, Book and Page Number recorded) Partnership Trust Other Limited Partnership Name and Address of the Registered Agent: Name Phone Number Address City State Zip 6. A registration was filed with the Securities and Exchange Commission on ________________and will be effective on __________ __. 7. List the states in which it is proposed to offer the securities for sale to the public: 8. List the states, if any, in which the securities are eligible for sale to the public: 9. List the states, if any, which have refused, by order or otherwise, to authorize sale of securities to the public, or have revoked or suspended the right to sell securities, or in which an application has been withdrawn: 10. General character and location of issuer's business: C. Documents Required By All Applicants Submitted herewith as a part of this application are the following applicable documents. Any document filed within the last five years may be incorporated herein by reference, to the extent that the document is currently accurate. It is requested, to the extent possible, that all documents be filed on standard (8 ½ x 11) letter size paper and that all copies be clear and legible. 1. 2. 3. A filing fee as set forth in Part "A" of this application. Nonprofit issuer registrations do not require a fee. An irrevocable Consent to Service of Process (Form U-2 or GA Form 6) If the issuer is a corporation, a director's resolution providing irrevocable corporate consent to service of process. (Form U-2A or GA Form 6A) A copy of the proposed prospectus, offering circular, placement memorandum or other similar document. Copies of documents required by the applicable code section or rule. 4. 5. Form 8 Rev. 2/2011 American LegalNet, Inc. www.FormsWorkFlow.com 2 D. To Be Signed By All Applicants This application is filed pursuant to the Georgia Uniform Securities Act of 2008, as amended. The application must be signed by an authorized agent of the issuer, any person on whose behalf the offering is to be made, a registered broker-dealer, or an authorized agent of any of the above. If this application is signed by an agent, submit a copy of a Power of Attorney authorizing the agent to execute the application. This _____________________Day of ______________________________, 20____________________ (SEAL) (Name of Applicant) ATTEST/Witness: (Authorized Signature) (Title of person Signing Application) E. Additional Signatures Additional signatures required for registration pursuant to O.C.G.A. §§10-5-23. DO NOT COMPLETE THIS SECTION FOR SEC Coordinated Filing Exemptions or Uniform Limited Offering Exemption filings (SEC Regulation D, Rules 505 & 506). Signature Title Date Chief Executive Officer Principal Financial Officer Comptroller or Principal Accounting Officer Form 8 Rev. 2/2011 American LegalNet, Inc. www.FormsWorkFlow.com This registration statement must be signed below by a majority of the issuer's Board of Directors or persons performing similar functions or, if there is no Board of Directors or persons performing similar functions, by the majority of the persons or board having the power of management of the issuer. For any member not signing, there must be attached, a written consent from such person to the filing of this registration statement and use of his/her name therein. (If additional space is needed, attach a separate page with heading, "Signature Page Number Two".) Signature Title Date Form 8 Rev. 2/2011 American LegalNet, Inc. www.FormsWorkFlow.com
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