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Application For Consent To Transfer Securities Pursuant To Section 25151 260.151(a) - California

Application For Consent To Transfer Securities Pursuant To Section 25151 Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .
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APPLICATIONFORCONSENTTOTRANSFERSECURITIESPURSUANTTO SECTION25151OFTHECORPORATESECURITIESLAW DBO­260.151(a)(Register2009,No.39)(Rev.08-13) (Department of Business Oversight Use Only) STATEOFCALIFORNIA­DEPARTMENTOFBUSINESSOVERSIGHT Fee Paid $ Receipt No. Department of Business Oversight File No. (Insert file no. of previous filings before the Dept. if any) FEE: $ (To be completed by applicant. The required fee is $20 per transfer (Sec. 25608(m), Corp. Code).) Date of Application: _________________ This represents (check appropriate box): The initial filings. An amendment to application dated THE SECURITIES PROPOSED TO BE TRANSFERRED ARE SUBJECT TO (CHECK APPROPRIATE BOX) LEGEND CONDITION. 1. ESCROW CONDITION. (a) Name of Issuer: ________________________________________________ (b) Former Name, If Any:____________________________________________ 2. Description of securities proposed to be transferred: (State title of each class of securities (e.g., Class A Common Stock). If rights, warrants and options are listed, also specify the securities to be transferred upon exercise thereof. If securities are to be pledged, so state.) ______ 3. Name and address of each transferor (if space is insufficient, incorporate and attach additional sheets): Aggregate number or amount of securities proposed to be transferred by each transferor: Name Address Total: American LegalNet, Inc. www.FormsWorkFlow.com APPLICATIONFORCONSENTTOTRANSFERSECURITIESPURSUANTTO SECTION25151OFTHECORPORATESECURITIESLAW DBO­260.151(a)(Register2009,No.39)(Rev.08-13) Page2of3 STATEOFCALIFORNIA­DEPARTMENTOFBUSINESSOVERSIGHT 4. Name and address of each proposed transferee (if space is insufficient, incorporate and attach additional sheets): Aggregate number or amount of securities proposed to be transferred Name Address by each transferor: Total: 5. Address of principal executive office of Issuer: (Number and Street) 6. (City) (State) (Zip Code) Name and address of person to whom correspondence regarding this application should be directed: Name (Number and Street) (City) (State) (Zip Code) 7. There are attached hereto as exhibits statements by each of the proposed transferees in the form required by Section 260.151 of Title 10 of the California Code of Regulations. (Note: Upon request, such statements will be treated as confidential by the Commissioner, subject to the provisions of Section 250.10, Title 10, California Code of Regulations.) (Check appropriate box) (a) There are no restrictions upon the transfer of the securities proposed to be transferred other than the legend or escrow condition imposed by the Commissioner of Corporations. (b) There are no restrictions upon the transfer of the securities proposed to be transferred other than the legend or escrow condition imposed by the Commissioner of Corporations which are described in an exhibit attached hereto and incorporated herein by reference. Such restrictions have been complied with as to make the transfer to the proposed transferees valid and are known to the proposed transferees. 8. 9. No portion of the consideration to be given by the transferees of the securities will be for the direct or indirect benefit of the Issuer identified in Item 1. (If the Issuer is to benefit from proposed transfer, see Section 25011 of the Corporate Securities Law of 1968 and Section 260.011 of Title 10, of the California Code of Regulations. Qualification of the transaction may be required. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATIONFORCONSENTTOTRANSFERSECURITIESPURSUANTTO SECTION25151OFTHECORPORATESECURITIESLAW DBO­260.151(a)(Register2009,No.39)(Rev.08-13) Page3of3 STATEOFCALIFORNIA­DEPARTMENTOFBUSINESSOVERSIGHT 10. Execution Instructions: If a transferor is other than an individual, the name of the entity should be typed or printed above the signature line exactly as shown in Item 3. The signature should show the name and title of the person authorized to sign for such transferor. I/We certify (or declare) under penalty of perjury under the laws of the State of California and I/We have read this application and know the contents thereof, and that the statements therein are true and correct. Executed at (Place) , (Date) , 20_____ (If the transferor is other than an individual, give the name of the entity and the name and title of the person executing the application on behalf of such entity.) (Signature of Transferor) (Signature of Transferor) (Signature of Transferor) (Signature of Transferor) (Signature of Transferor) (Signature of Transferor) American LegalNet, Inc. www.FormsWorkFlow.com
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