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Agent Of The Issuer Examination Waiver Request NJBOS-15 - New Jersey

Agent Of The Issuer Examination Waiver Request Form. This is a New Jersey form and can be used in Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 9/30/2005
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NEW JERSEY BUREAU OF SECURITIES th 153 Halsey Street, 6 Floor, Newark, NJ 07102 Post Office Box 47029, Newark, NJ 07101 (973) 504-3600 AGENT OF THE ISSUER EXAMINATION WAIVER REQUEST The New Jersey Bureau of Securities requires a prospective agent of the issuer to pass the Series 7 (General Securities Representative) examination. This form should be used to request a waiver of this examination requirement and should be filed with the New Jersey Bureau of Securities at the address above. For additional information regarding issuer agent registrations, examinations, and waivers, please call (973) 504-3661. Name of Issuer (company): _____________________________________________________ Street Address: ________________________________________________________ _______ City: _______________________________ State: _____________ ZIP Code: ___ _________ Name of Issuer Agent (individual): _______________________________________ ________ Office Telephone Number: _____________________________________________________ Type of Securities (common stock, warrants, bonds, etc.): ____________________________ The undersigned hereby certify as follows: 1. The issuer agent and the issuers executive officers would not be disqualified from conducting offers and sales of the issuers securities by Regulation A under the Securities Act of 1933. 2. The issuer agent has the following securities-related experience: a. Nature of duties: _______________________________________________ __________ b. Name of employer(s): _____________________________________________________ Signature of Officer of the Issuer: Signature of Applicant: _________________________________ _________________________________ Title: ____________________________ Date: ____________________________ Date: ____________________________ Form NJBOS-15, 7/2004 American LegalNet, Inc. www.USCourtForms.com
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