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Georgia Coordination And Regulation A Filings Application To Register Securities GA-U1 - Georgia
| Georgia Coordination And Regulation A Filings Application To Register 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 2 Martin Luther King, Jr. Drive, S.E. Ste 802, West Tower Atlanta, Georgia 30334 (404) 656-3079 http://www.sos.state.ga.us/securities/ CATHY COX H. WAYNE HOWELL Secretary of State Georgia Coordination and Regulation A Filings Application Director To Register Securities Pursuant to Section 10-5-9(5) of the Georgia Securities Act Filing fee $250 payable to Georgia Secretary of State Applicant/Issuer Information Name of Issuer Address Telephone Number City State Zip Code Contact Information (correspondent to whom notices and communications regarding this application may be sent) Name Address Telephone Number City State Zip Code Registration or acceptance for filing is sought for the following described securities in the amounts indicated Total Offering Offering in Georgia Offering Price Number Of Number of Description Of Or Proposed Shares Or Amount Shares Or Amount Securities Offering Price Units $ Units $ Totals $ $ Indicate the maximum commission to be charged: % Amount of enclosed filing fee $ Date Registration Statement filed with Securities and Exchange Commission Effective date of registration with Securities and Exchange Commission List states in which it is proposed to offer the securities for sale to the public List states, if any, in which the securities are eligible for sale to the public List the states, if any, which have refused, by order or otherwise, to authorize sale of the securities to the public or have revoked or suspended the right to sell the securities, or in which an application has been withdrawn Form GA-U1 8/2002 <<<<<<<<<********>>>>>>>>>>>>> 2 Subm itted herewith as a part of this application are the following documents (documents on file may be incorporated by reference): (a) One copy of the Registration Statement in the latest form on file under the Securities Act of 1933 (b) Consent to service of process The applicant hereby applies for registration or acceptance for filing of the above described securities under the law cited above and in consideration thereof agrees so long as the registration remains in effect that it will: (a) Advise the above named state authority of any change prior to registration in this state in any of the information contained herein or in any of the documents submitted with or as a part of this application. (b) File with the above named state authority within two business days after filing with the Securities and Exchange Commission (i) any amendments other than delaying amendments to the federal registration statement, designating the changed, revised or added material or information by underlining the same; and (ii) the final prospectus, or any further amendments or supplements thereto. (c) Notify the above named state authority within two business days (i) upon the receipt of any stop order, denial, order to show cause, suspension or revocation order, injunction or restraining order, or similar order entered or issued by any state or other regulatory authority or by any court, concerning the securities covered by this application or other securities of the issuer currently being offered to the public; and (ii) upon the receipt of any notice of effectiveness of said registration by the Securities and Exchange Commission. (d) Notify the above named state authority at least two business days prior to the effectiveness of said registration with the Securities and Exchange Commission of (i) any request by the issuer or applicant to any other state or regulatory authority for permission to withdraw any application to register the securities described herein; and (ii) a list of all states in which applications have been filed where the issuer or applicant has received notice from the state authority that the application does not comply with state requirements and cannot or does not intend to comply with such requirements. (e) Furnish promptly all such additional information and documents in respect to the issuer or the securities covered by this application as may be requested by the above named state authority prior to registration or acceptance for filing. Signature of Officer, Dealer, Limited Dealer or Authorized Agent: Title of person signing: Date: Form GA-U1 8/2002
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