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Notice Registration Of Agent - Idaho
| Notice Registration Of Agent Form. This is a Idaho form and can be used in Securities Bureau Department Of Finance Blue Sky Secretary Of State . |
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NOTICE REGISTRATION OF AGENT TO: THE DIRECTOR OF THE DEPARTMENT OF FINANCE OF THE STATE OF IDAHO: This is to notify you that (issuer) proposes to offer its securities in Idaho pursuant to Section 30-1435(1), Idaho Code, and Rule 270 thereunder and has appointed, and hereby registers (agent) ,(SSN) , (addr ess) as its agent for the purpose of said of fering, which is more particularlydescribed in Form D filed with your Department on the day of ,2 0 . It is further understood that said agent is registeredonly for the above describedoffering and such registrationis effective only until such offering has been completed. It is further understood that this registrationshall become effectiveten (10) days after receipt by you unless you have objected thereto and that it may be denied or revoked for reasons specified in Section 30-1413, Idaho Code. IN WITNESS WHEREOF, I, (name of Officer/Partner) (title) of the above-named issuer, whose address is: have hereto set my hand and caused the seal of said issuer to be affixed this day of ,2 0 . (signature) AGENTS QUESTIONNAIRE 1. Full Name: Address: Birthplace: Birth date: SSN: 2. Were you ever engaged or occupied as a salesman of securities in this or any other state? If the answer is "yes", explain by completing Page 2 of this questionnaireand attaching a separate sheet to be marked Exhibit 1, if necessary. 3. Have you ever been denied the right to sell or solicit for sale any securities in this or any other state? If so, give date, place, name of employer and state the reasons assigned for each denial in detail, on attached separate sheet marked Exhibit 2. 4. Have you ever been the subject of any Order, Judgment or Decree of any court te mporarily, preliminarilyor permanentlyrestraining or enjoining you from engaging or cont inuing any conduct or practice involvingsecurities? If so, explain f ully, giving dates, places and circumstanceson attached sheet to be marked Exhibit 3. 5. Have you ever been convicted of the commission of any crime or crimes, or is there any action pending, other than trafficviolations? If so, explain when, where, what the nature of the charge was on a separate attached sheet to be marked Exhibit 4. 6. Have you ever been suspended or barred from the practice of any profession? If so, explain fully, attaching separate sheet to be marked Exhibit 5. 7. Have you or any organizationowned or controlled by you or in which you were an officer, director or partner ever been the subject of any insolvency or bankruptcy proceeding? If so, state when, with detail of settlement on attached sheet marked Exhibit 6. 8. Have you ever been discharged by an employer or requested to resign or otherwise severed your business relations with any person because of misrepresentationmade by you, or claimed to have been made by you, in connection with the sale of securities? If so, give details on attached sheet to be marked Exhibit 7. 1 <<<<<<<<<********>>>>>>>>>>>>> 2 PREVIOUS RESIDENCE, EMPLOYMENT, ETC., FOR PAST TEN YEARS (Replies must be full and complete) Residential History Street City State Zip From ToEmployment History - Account for all time for the past ten years. Give all employmentexperiencestarting with your previous employer and working back ten years. Include full and part-timework,self-employment,military service, unemploymentand full-timeeducation. (Attachseparatesheet ifnecessary) Employer Address Position From To Employer Address Position From To Employer Address Position From To Employer Address Position From To Employer Address Position From To If heretofore engaged in the sale of any stocks, notes, contracts, or other securities ofwhatsoeverkind or characteror if otherwiseeng aged as a salesman,sales agent or principalin thepromotion of any business by whatsoever means calculated to procure funds from investors, give style or name of issuer and purpose for which organized. If not so engaged, write "none" afterIssuer and Purpose. Issuer Purpose 2 <<<<<<<<<********>>>>>>>>>>>>> 3 Signature of Applicant STATE OF ) ) ss. County of ) , being first dully sworn on oath, states he/she has read and knowingly made the foregoing state ments and representationsand that each and all of such statements and representationsare true. Subscribedand sworn to before me, a Notary Public in and for the aforesaid count and state, this day of 20 . ____________________________ Notary Public Residing at: My Commission expires: G:\USERS\KWITT\NOTICEAG.FRM 3
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