Nevada > Secretary Of State > Blue Sky > Securities Division
Claim Of Exemption From Securities Registration N-9 - Nevada
| Claim Of Exemption From Securities Registration Form. This is a Nevada form and can be used in Securities Division Blue Sky Secretary Of State . |
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ROSS MILLER Secretary of State 555 East Washington Ave., #5200 Las Vegas, Nevada 89101 Phone (702) 486-2440 Fax (702) 486-2452 Website: www.nvsos.gov Nevada Form N-9 Claim of Exemption From Securities Registration PAGE 1 ABOVE SPACE FOR OFFICE USE ONLY Expedite Service Request: 24 Hours $100.00 Same Day $200.00 1. The undersigned hereby claims an exemption from securities registration pursuant to: 2. The following information is submitted: Name of issuer Address of issuer Street Address City State Zip Code (cite authority) Telephone: 3. Issuer's state of incorporation or jurisdiction of organization: Date of incorporation or organization: 4. Issuer's fiscal year end date: 5. Form of organization: (check one) Corporation Other (specify) 6. Type of business: (check one) Manufacturing Other (specify) 7. Submitted by: Name of submitter Address of submitter Street Address City Fax: Limited-Liability Company Limited Partnership Service Real Estate State Zip Code Position with issuer: 8. Type of security: Debt Equity Other (describe) Telephone: 9. Title of class of securities to be sold in this offering: 10. Total number of shares or units of securities to be sold in this offering: Nevada Secretary of State Securities Form N-9 Page 1 Revised 12-24-12 American LegalNet, Inc. www.FormsWorkFlow.com ROSS MILLER Secretary of State 555 East Washington Ave., #5200 Las Vegas, Nevada 89101 Phone (702) 486-2440 Fax (702) 486-2452 Website: www.nvsos.gov Nevada Form N-9 Claim of Exemption From Securities Registration PAGE 2 ABOVE SPACE FOR OFFICE USE ONLY 11. Aggregate dollar amount of the offering: 12. Price per share or unit of securities to be sold: 13. Total number of purchasers other than accredited investors to whom securities are to be sold: 14. Total number of shares/dollar amount of securities claimed to be exempt: 15. Past securities sales. List all securities sold by the issuer within the 12 months preceding the filing of this form. Attach a plain 8 1/2" x 11" sheet if additional space needed. Date of Sale Description of Security Amount Basis on which securities were sold, i.e. Exemption or Registration under Federal Securities Act of 1933 16. If this filing is made pursuant to the exemption provided by NAC 90.519 a marked copy of the Preliminary Official Statement or other disclosure document is attached. 17. The following fee is enclosed in the form of a check payable to the Secretary of State, Securities Division. Filing Fee Expedite Fee Total Enclosed No Fee Required (cite authority) 18. Signature: The undersigned officer or person acting in a similar capacity has duly caused this notification to be filed on behalf of the issuer. Issuer: Date: X (signature) Name and Title: NOTE: For acknowledgment, enclose one additional copy of this filing and a self-addressed stamped envelope. ***FOR OFFICIAL USE ONLY*** Date/Time Received: Receipt Number: Date Exemption Expires: Nevada Secretary of State Securities Form N-9 Page 2 Revised 12-24-12 American LegalNet, Inc. www.FormsWorkFlow.com File Number: Entered By:
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