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Request For Waiver Of Procedures Under Regulation 504 RO - Pennsylvania
| Request For Waiver Of Procedures Under Regulation 504 Form. This is a Pennsylvania form and can be used in Securities Blue Sky Department Of State . |
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PSC/FORM RO EFFECTIVE: 7/7/90 REVISED: l/l/00 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COMMISSION Request for Waiver of Procedures under Regulation 504.060(b) RESCISSION OFFERS" 1. Exact Name of Offeror: 2. Address of Principal Office of Offeror: Number and Street City State Zip Code Telephone No. 3. Name and address of person to whom correspondence on this filing should be sent: Name Title Number and Street City State Zip Code Telephone No. 4. (A) Legal Form of Offeror (Corporation, Partnership, Individual, et c.): (B) If Offeror not an individual, designate state of incorporation o r formation: (C) State the names and addresses of the general partner, promoter, and chief executive officer, chief operating officer and chief financial officer of the Offeror. Complete (D) through (F) only if Offeror is the Issuer. (D) If anyone in (C) has held a similar position with another perso n (not the Issuer) which made a rescission offer in Pennsylvania within the Past 5 years, state the name of the person and date of the rescission offer. If none, so state. (E) Has the Issuer made a rescission offer in Pennsylvania within th e last 5 years?YES NO [ ] [ ] (F) Does the Issuer plan to continue offering securities for sale in Pennsylvania which are the subject of the rescission offer? If yes, upon which section of the Act will the Iss uer rely?YES NO [ ] [ ]5. Has the general partner, promoter, chief executive officer, chief operat ing officer, chief financial officer or owner of 20% or more of any class of securities of the Issuer been convi cted of any crime or made the subject of any sanction or otherwise found to have met any of the criter ia described in Section 305(a)(ii)- (ix) of the Act? YES NO [ ] [ ] If yes, describe fully. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 26. (A) Describe the type and price per unit of securities subject to th e rescission offer. (B) For each sale of securities covered by this rescission offer, pr ovide in columnar form the name and address of each Pennsylvania purchaser, the date of sale, and the dollar amount of securities purchased. 7. (A) Provide the name and address of the person who effected the trans actions which are now the subject of the rescission offer. (B) Were sales commissions or other remuneration paid directly YES NO or indirectly on the securities transactions? If yes, explain. [ ] [ ] If the response to (B) is yes, complete (C) and (D) as applicable: (C) Were the transactions subject to the rescission offer effected t hrough a Broker-Dealer? YES NO If yes, complete (i) and (ii) below. [ ] [ ] (i) Is the Broker-Dealer registered in Pennsylvania? YES NO [ ] [ ] If yes, state name, address and CRD Number. (ii) If the Broker-Dealer is not registered in Pennsylvania, describe how the Broker-Dealer has complied with Section 301 of the Act. (D) Were the securities subject to the rescission offer sold directl y by a person registered in Pennsylvania as an Agent or a Principal of a Broker-Dealer? YES NO If yes, provide the following information: [ ] [ ] Agents Name Agents CRD Number Broker-Dealer Number and Street of Broker-Dealer Office Involved in the Sale City State Zip Code Telephone No. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 38. Each Offeror executing this Waiver Request hereby represents that: (A) The Offeror, by his signature below, and, if the Offeror is the Issuer, the general partner, promoter, chief executive officer, chief operating officer and chief financial off icer of the Issuer, by their signatures below, is aware of the need to comply with the provisions of the Act in the future, particularly if such person serves in the same or similar position with another person (not the Offeror). The signature of a person identified in this paragraph is not required if that person was not affiliated with the Offeror when the sales of securities which are the s ubject of this rescission offer occurred. SIGNATURE TYPED NAME TITLE DATE (B) The Offeror is familiar with the provisions of section 504 of the Act an d regulations adopted thereunder. (C) The statements made herein, including attachments hereto, are not incomp lete in any material respect or false or misleading with respect to a material fact. (D) The Offeror will advise Commission staff of the results of the rescissio n offer within 15 calendar days after the expiration of the rescission offer period. IN WITNESS WHEREOF, this Waiver Request has been duly executed thisday of ,19 . (NAME OF OFFEROR) By: (Title) American LegalNet, Inc. www.USCourtForms.com
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