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Application For Registration As Issuer-Dealer I - Nebraska
| Application For Registration As Issuer-Dealer Form. This is a Nebraska form and can be used in General Blue Sky Secretary Of State . |
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BUREAU OF SECURITIES - DEPARTMENT OF BANKING State of Nebraska Application for Registration as Issuer-Dealer The undersigned hereby makes application for registration as an Iss uer-Dealer in securities within the State of Nebraska. The facts herein stated are tr ue and constitute a fair and complete statement of all material facts relating to this app licant. 1. Name of Applicant 2. Form of organization (sole proprietorship, partnership, corporation , etc.), and date of organization. 3. Principal address 4. Nebraska address 5. The names and addresses of the officers and directors if a corporati on, or all partners if a partnership, and all agents, are as follows: Name Official Capacity Address 6. Officer(s) who will take Nebraska Securities Examination. A five d ollar examination fee for each member is enclosed. 7. Attached hereto is a current financial statement. 8. Describe briefly the general character of the business conducted, or proposed to be conducted by the applicant. 9. In what states is applicant now licensed or registered? 10. Has any license or registration or application of this applicant, i n any state, been refused, suspended, cancelled, or revoked? 11. Has applicant, or any of its members, officers, or directors ever b een charged with fraudulent acts or violations of any law in connection with the sal e of securities? 12. Has applicant, or any of its members, officers, or directors ever b een convicted of a crime involving the sale of securities? 13. Has applicant, or any of its members, officers or directors ever be en convicted of a felony? 14. Has applicant been declared a bankrupt or been in the hands of a re ceiver? American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 215. Of what stock exchange is applicant a member? 16. Has applicant been refused membership in, or suspended or expelled from, any stock exchange? 17. Applicant agrees to report within thirty days, any material adverse change in assets or liabilities. 18. What classes of securities will be dealt in? 19. Has the applicant or any officer, partner, director, executive offi cer, or salesman been a subject of formal complaint proceedings brought by the Natio nal Association of Securities Dealers, Inc., the Securities and Exchange Commission , or any other State, or are any such proceedings pending at the present time? 20. Is applicant a member of the National Association of Securities Dea lers? 21. Name one or more banks as a credit reference 22. Name five persons or firms as general references. Name Address Applicant agrees that this application is made for the limited purpose o f selling its own securities. Applicant further agrees that it will not conduct a general securities business. WHEREFORE, applicant prays that it be registered as an Issuer-Deale r under the Nebraska Securities Act. (Issuer-Dealer) By: (President or Partner) By: (Secretary or Partner) (CORPORATION SEAL) STATE OF ) ) SS. COUNTY OF ) , being first duly sworn, deposes and says that he is of the applicant named above; that he has full authority to sign said application; that he has read said application and knows the conten ts thereof; and that the statements therein made are true. SUBSCRIBED and sworn to before me this day of , 19 . (Notary Public) NOTARIAL SEAL American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 S I G N A T U R E B O N D KNOW ALL MEN BY THESE PRESENTS: That , asprincipal, of , isheld and firmly bound unto the State of Nebraska for the use and benefit of any person who has cause of action under 8-1118, or exchange of securiti es by the principal in the sum of $25,000, for the payment of which, I do bind mys elf and my heirs, executors, administrators and successors by these presents. The condition of the above obligation is such that if the principal shall comply with all of the laws of the State of Nebraska pertaining to the issuance, sale or exchange of securities and shall promptly account for all money and securities received by him and shall not unlawfully or dishone stly appropriate or apply any funds held, received by or entrusted to him, an d shall satisfy all judgments entered in actions against him arising out of the issuance, sale or exchange of securities, then the obligation shall be void; other wise to remain in full force and effect. This Agreement shall be effective from the date of its approval by the Department of Banking and Finance of the State of Nebraska and shall con tinue in force and effect until forty-five days after receipt of written notice o f can- cellation from the principal of the Department of Banking and Finance to the State of Nebraska. Signed at on . IN THE PRESENCE OF: Principal American LegalNet, Inc. www.USCourtForms.com
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