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Certification Form 10-2-1B - Utah

Certification Form Form. This is a Utah form and can be used in Securities Blue Sky Department Of Commerce .
 Fillable pdf Last Modified 10/6/2005
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(Rev.11/16/98) STATE OF UTAH DEPARTMENT OF COMMERCE DIVISION OF SECURITIES FORM 10-2-1B Certification STATE OF ) ) ss. COUNTY OF ) The undersigned, an officer, director, promoter, holder of 10% of the outstanding stock, underwriter or sales agent, or attorney for (the "Company"), being first duly sworn, does hereby certify under oat h that the information in the Companys registration statement submitted to the Utah Department of Commerce, Di vision of Securities is true, accurate and complete to the best of his or her know ledge and that he or she has been diligent in confirming there are no promoters, material transactions, p ayments to related parties, stock distribution arrangements or material compensation arrangements which a re not disclosed in the registration statement. Dated Signature Affiliation with Company Subscribed and sworn to before me this day of , 19 . Notary Public American LegalNet, Inc. www.USCourtForms.com
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