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Application For Qualified Business Tax Credit Status QBR - North Carolina

Application For Qualified Business Tax Credit Status Form. This is a North Carolina form and can be used in Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 9/25/2009
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STATE OF NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE Securities Division P.O. Box 29622 Raleigh, North Carolina 27626-0622 (919) 733-3924 APPLICATION FOR REGISTRATION/RENEWAL as a QUALIFIED BUSINESS THE MISREPRESENTATION OF ANY FACT HEREIN CONSTITUTES A VIOLATION OF LAW. (PLEASE FURNISH INFORMATION REQUESTED BELOW) Legal Name of Applicant Business: _________________________________________________________________ To the Secretary of State of North Carolina: Pursuant to the provisions of 105-163.013 of the North Carolina General Statutes, we submit the following information and certify the following facts to apply for registration of the undersigned business as a (check one of the following): QUALIFIED BUSINESS VENTURE (as defined in N.C.G.S. 105-163.010(8)); QUALIFIED GRANTEE BUSINESS (as defined in N.C.G.S. 105-163.010(9));or QUALIFIED LICENSEE BUSINESS (as defined in N.C.G.S. 105-163.010(9a)). This Application for Registration is for (check one): INITIAL REGISTRATION RENEWAL OF REGISTRATION REINSTATEMENT AFTER REVOCATION OF REGISTRATION RE-REGISTRATION AFTER REVOCATION OF REGISTRATION American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 I. GENERAL INFORMATION (to be submitted by all applicants): 1. Name, address, telephone number, and fiscal year of Applicant Busine ss: Legal Name: _____________________________________________________________________ _________ Street address: _______________________________________________________ ______________________ Mailing address: _______________________________________________________ _____________________ City, State, Zip Code: ________________________________________________ _______________________ Telephone number: (______) _______________________________________________________ __________ Fiscal year end (month and day): _______________________________________________________ _______ 2. Employer Identification Number (or Social Security Number, for a propri etor: SSN is voluntary): ________________________________________________________________________ ________________ Check here if Applicant has applied for but has not received an E.I.N. 3. Type of business organization: Proprietorship Limited Partnership Corporation Limited Liability Company General Partnership Limited Liability Partnership Attach a copy of the documents under which the Applicant Business is organized (i.e., Articles of Incorporation, Articles of Organization, Certificate of Limited Partnership, etc.) to this Application for Registration. 4. Identify the Applicant Business Authorized Representative (see Instruction 7 for further details): Name: _____________________________________________________________________ ______________ Title: ________________________________________________________________ ____________________ Street Address: _______________________________________________________ _____________________ Mailing Address: ______________________________________________________ _____________________ City, State, Zip Code: ________________________________________________ _______________________ Telephone: (_____) ________________________ Facsimile: (_____) _______________________________ E-mail Address: ____________________________________________________________ ________________ 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 5. If Applicant Business is a Corporation, Limited Liability Company, or Limited Partnership, set forth the date and state or country of incorporation, organization, or f ormation: Date: _________________________________________________________________ ___________________ State or Country of Formation: ______________________________________________________________ 6. Address of the Applicant Business business headquarters if different from the address shown in Item 1: ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ 7. Location of the Applicant Businesses principal business operations: County:_________________________________________________________________ __________________ State or Country:_______________________________________________________ ____________________ 8. Give a summary of the business activities in which the Applicant Business engages (attach additional pages if necessary): ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ ________________________________________________________________________ __________________ 9. Check this item ONLY if applicable: Minority Business. The Applicant Business is at least fifty-one percent (51%) owned by one or more minority persons (as defined in N.C.G.S. 143-128), or in the case of a corporation, its stock is at least fifty-one percent (51%) owned by one or more minority persons. Additionally, its management and daily business operations are controlled by one or more of the minority persons who own it. 3 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 10. Complete these two items ONLY if this is an application for renewal of registration as a Qualifie
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