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Public Records Request DFI-PD-SEC-400 - Washington
| Public Records Request Form. This is a Washington form and can be used in Securities Blue Sky Secretary Of State . |
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Department of Financial Institutions PUBLIC RECORDS REQUEST SECURITIES DIVISION PO Box 9033 Olympia, WA 98507-9033 (360) 902-8760/FAX: (360) 902-0524 Securities Date Stamp PLEASE PRINT Do not send any money until you are notified of the cost PERSON REQUESTING Name Company Mailing Address City, State, ZIP Telephone Number ( ) FAX Number ( ) NAME OF PUBLIC RECORD Check document requested. Please specify which record is required and w hether the document should be the most recent date or a particular year. Name of Company or Individual Date of Document Offering Circular (Prospectus) Franchise Agreement Financial Statements Application Form Correspondence Impound Agreement Articles Of Incorporation Consent To Service Of Process Permit To Sell Advertising Materials Salesperson Disclosure Form Underwriters Agreement Other (specify) Escrow Information CONDITIONS FOR RELEASE OR REVIEW OF PUBLIC RECORDS I agree that any list of individuals provided to me will not be used for any commercial purpose by myself or any other person I represent. I will protect the information from access by anyone who may use it for a comme rcial purpose, which means using the information for profit-making activities. If I wish to inspect or review record(s), I agree to the following con ditions: I will not remove the records from the designated area. The q uantity of records may be limited. I will not mark or alter the records in any way. I will not destroy or deface the records in any way including writing on, folding or folding anew if in folded form, tracing or fastening with clips or other fasteners except those that already exist in the file. I will not cut or mutilate records in any way. I will keep the records in the order received. And I will return the records to the department when no longer required by me and no later than the end of customary office hours on th e day provided. Signature of Person Requesting Public Document Date The minimum charge is $.15 per page. If the total is less than $1.50, the fee may be waived. Please pay by check made payable to the Washington State Treasurer. NSF checks will be subject t o a $15.00 fee. Signature Authorizing Release of Records Date Number of copies Date person contacted Date request completed Cost $___________ Comments Below: Tax $___________ TOTAL DUE $ DFI-PD-SEC-400 (12/03) American LegalNet, Inc. www.USCourtForms.com
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