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Registration By Qualification Biographical Information 8-1 - Georgia

Registration By Qualification Biographical Information Form. This is a Georgia form and can be used in Securities And Business Regulation Blue Sky Secretary Of State .
 Fillable pdf Last Modified 8/19/2011
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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 DIRECTOR/OFFICER Form 8-1 Registration by Qualification - Biographical Information Georgia Uniform Securities Act of 2008, as amended O.C.G.A. ยง10-5-23 Issuer (Name and Address): Director/Officer Full Name & Title Date of Birth Business Address (Number and Street) Residence Address (Number and Street) SOCIAL SECURITY NUMBER Place of Birth City City State State Zip Code Zip Code Present Occupation or Profession Phone Number Give detailed statement of employment history for the past five years. Provide character and period of each employment and reasons for resignation or discharge. Provide dates of employment as well as present addresses of employers. Attach additional sheets as necessary. Name and address of Employer Name and address of Employer Name and address of Employer Name and address of Employer Name and address of Employer Position Held Position Held Position Held Position Held Position Held From From From From From To To To To To Reason for Leaving Reason for Leaving Reason for Leaving Reason for Leaving Reason for Leaving Do you or your spouse, legally and/or beneficially, own securities in this Issuer? (If so, how many shares?) In what manner did you pay for them? (If in cash, state dollar amount. If other than cash, please specify.) Purchased by whom? List all transactions (including amounts paid and dates acquired) in Issuer's securities, legally and/or beneficially, owned by you or your spouse during the past two years. If none, so state. (You may attach a statement explaining these transactions and label it "Exhibit 1") Please describe any material interest in any material transaction between the Issuer (and/or any significant subsidiary) and you (including your spouse) effected within the past three years (or proposed to be effected). If none, so state. (You may attach a statement explaining these transactions and mark it "Exhibit 2") Have you or your spouse any contract for additional securities in the Issuer? (If yes, attach a statement explaining fully the contract and mark it "Exhibit 3") Have you or your spouse any verbal or secret agreement with any other officer or affiliate of Issuer whereby you are to obtain additional securities in Issuer? (If yes, attach a statement explaining fully your agreement and mark it "Exhibit 4") What salary do you receive from the issuer? What other remuneration? Yes Yes No No Have you been arrested, convicted, pled guilty, or entered a nolo contendere plea (or is there currently pending any proceeding against you) of a crime involving the sale or offer of securities? (If yes, attach explanation and mark it "Exhibit 5" Has disciplinary action been taken against you (or is there pending disciplinary proceeding against you) by the Securities and Exchange Commission, the National Association of Securities Dealers, any state securities regulatory authority, any self-regulatory organization, and/or the Georgia Securities Commissioner? (If yes, attach explanation and mark it "Exhibit 6") Signature of Director/Officer: Yes No Yes No Date: Form 8-1 Rev. 2/2011 American LegalNet, Inc. www.FormsWorkFlow.com
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