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Report On Sales Of Securities 209 - Pennsylvania
| Report On Sales Of Securities Form. This is a Pennsylvania form and can be used in Securities Blue Sky Department Of State . |
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FILE NO.: FORM 209 EFFECTIVE: 10/11/97 REVISED: 12/23/04 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COMMISSION PART I Issuer Information 1. Exact Name of Issuer: 2. Address of Principal Office of Issuer: Number and Street City State Zip Code Telephone No. 3. Name and address of person to whom correspondence regarding this fi ling should be sent: Name Title Number and Street City State Zip Code Telephone No. PART II Report of Sales of Securities Registered under Section 206. 4. Date of effectiveness of registration statement under Section 206 5. (A) Offering in Pennsylvania: (i) Total number of shares or other units: (ii) Per share or unit price: (iii) Maximum aggregate offering price: (B) Sales in Pennsylvania: (i) Number of shares or other units: (ii) Aggregate proceeds received: Each of the persons executing this report on behalf of the Is suer hereby affirms that the statements made herein, including all attachments hereto, are not incomplet e in any material respect or false or misleading with respect to any material fact. Each of such per sons further affirms that he is familiar with the penalties contained in the Pennsylvania Securities Act of 1972, and all regulations adopted thereunder for making any false or incomplete statement in conn ection with the sale of a security or inany filing with the Commission. IN WITNESS WHEREOF, this report has been executed on . (insert date) (Name of Issuer) By: (Title) American LegalNet, Inc. www.USCourtForms.com
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