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Application For Retroactive Registration 391 - Ohio
| Application For Retroactive Registration Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF OHIO Telephone File Number Department of Commerce (614) 644-7381 Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 391 Registrant Must Not fill In. Division Record -- Date Checked By Notation Filing Fee Received Penalty Fee Received Record Made Accepted for Filing Not Eligible For Filing Prior Registration (Registrant Must Not Fill In.) (Section) (File) (Date) (Amount) (Description) (Price)This Registration (Registrant Must Not Fill In.) (Section) (File) (Date) (Amount) (Description) (Price)1. Issuers Name Payers Federal Tax Identification Number2. Issuers Address 3. Attach a notarized statement from issuer or counsel using the following language regarding harm to the investors: "No purchaser or offeree of the securities sought to be exempted, qualified or registe red pursuant to Section 1707.391 of the Revised Code was prejudiced by the failure to timely or properly exempt, qualify, or regi ster the securities." 4. Attach a notarized statement from the issuer or counsel stating the reas on for failure to timely or properly file, and the number of times during the preceding twelve months the issuer has filed a Form 391 . 5. Indicate number of Ohio purchasers of Securities to be qualified by comp leting the following. Dates of Original Sales Number of Purchasers Units Purchased Total Dollar Amount From To on those Dates Name of Issuer Name (Printed) Title Signature Date THE 391 FILING MUST INCLUDE A COPY OF THE APPROPRIATE FORM THAT IS TO BE CORRECTED, THE NOTARIZED STATEMENTS, AND PAYMENT OF THE REQUIRED FEE IF NOT ALREADY PAI D, PLUS A PENALTY FEE EQUAL TO SUCH REQUIRED FEE. nd Make checks payable to OHIO DIVISION OF SECURITIES, and send to 77 South High Street, 22 Floor, Columbus, Ohio 43215-6131 Correspondence regarding this form should be sent to: COM 4543 (Rev. 2/05) American LegalNet, Inc. www.USCourtForms.com
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