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Application For Qualification By Permit 260.113 - California

Application For Qualification By Permit Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .
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STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO ­ 260.113 (Rev. 08-13) APPLICATION FOR QUALIFICATION BY PERMIT (SECTION 260.113) An application for the qualification of the offer and sale of securities by permit pursuant to Section 25113 of the Code shall, in addition to the facing page required by Section 260.110 of these rules and items 8 through 10 and 12 through 18 specified in Section 260.112 of these rules, continue in the following form: (Note: The applicant's response to Item 21(j) of the application for qualification by permit pursuant to Corporations Code Section 25113 incorporates the information requested by Item 11 of Section 260.112 of these rules. Consequently, applicant's response to Item 11 should be "see response to Item 21(j)." In addition, the small company applicant's response to items of Section 260.112 and Section 260.113 of these rules may incorporate the information contained in the Form U-7 by referring to the appropriate page and question number of the Form U-7.) ITEM 19. PRIOR ISSUANCES PURSUANT TO CODE SECTIONS 25102(f) AND (h). If the applicant has previously issued securities pursuant to the exemptions from qualification provided for in Sections 25102(f) and/or (h) of the Code, briefly state the details of the transaction or transactions. ITEM 20. ADDITIONAL INFORMATION REQUIRED IN CONNECTION WITH INTEREST OR PARTICIPATION IN OIL, GAS OR MINING LEASES; REAL ESTATE SYNDICATES; AND MUTUAL WATER COMPANIES AND CHURCHES. (i) Interest or participation in oil, gas or mining titles or leases: The following, if appropriate: (a) A description of the properties involved and copies of all conveyances, assignments, leases, subleases or other instruments or agreements relating to said properties together with an opinion of counsel or title policy indicating that applicant has title to such properties. (b) A statement of the area of interest to the applicant, a description of the plan of exploration including, where available, anticipated drilling depth, the horizon or horizons in which hydrocarbon substances are expected and the nature of such hydrocarbons, the estimated costs of drilling and completing the well or wells proposed to be drilled, and the availability of a market or markets for hydrocarbons discovered. (c) In the case of programs other than wildcat drilling, a geological report and appraisal which indicate the proposed method of development and production, a statement of the method used in preparing such report, together with supporting geological and engineering data, a table setting forth the estimated future production and the present value thereof, together with a statement of the factor or factors used in making such estimate, and an estimate of the expenses to be incurred in connection with development and production of minerals as proposed in such geological report. (d) If the securities proposed to be issued involve minerals other than oil, gas or other hydrocarbons, the applicant shall include a mineral report which indicates the area of interest to the applicant, the geological information available to such applicant with respect to such area, the results of other mineral operations in the area, if known, a description of the plan of operation including, where available, the extent of ore deposits, the cost of development and production thereof, the market or markets for minerals produced and the cost of marketing such minerals. (e) Copies of all instruments or agreements which will convey an interest in minerals to the proposed purchasers and a statement of the ownership of other interests in the same minerals. In the event that there is a relationship or an arrangement between one or more holders of such an interest in minerals and the applicant, the nature thereof shall be described. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO ­ 260.113 (Rev. 08-13) Page 2 of 4 APPLICATION FOR QUALIFICATION BY PERMIT (SECTION 260.113) (ii) Real Estate Syndicates: The following if appropriate: (a) A copy of an appraisal of the property of recent date should be attached hereto as an additional exhibit. In lieu of an appraisal, in cases where the property is being acquired from other than a promoter of the applicant and where no real estate commission in connection with the acquisition is being paid to anyone related to the applicant, a valuation of the property may be submitted together with a detailed description of the method of valuation. (b) Such other information as may be necessary to demonstrate compliance with Sections 260.140.110.1 through 260.140.119.1 of Title 10 of the California Code of Regulations. (iii) Mutual Water Companies: An application for a permit to offer and sell securities of a mutual water company must demonstrate compliance with Sections 260.140.71 through 260.140.71.10 of Title 10 of the California Code of Regulations. (iv) Church debt securities: An application for permit to offer and sell church debt securities must demonstrate compliance with Sub article 7.2, Article 4, Subchapter 2 of these rules. ITEM 21. EXHIBITS. Attach and incorporate by reference the following exhibits: Note: Any exhibit which is inapplicable should be listed by letter on the form followed simply by the word "inapplicable." A. A copy (which may be in the form of a restated or composite copy) of applicant's charter documents as described in Section 260.001 of Title 10 of the California Code of Regulations. B. Specimen certificate evidencing the security to be issued. (Instruction: Certificates for common stock which are to be in a standard printer's form without any additional substantive provisions should not be submitted.) C. A copy of any contract made or to be made by the issuer affecting any of the rights, preferences, privileges or transferability of the securities. D. Subject to the following instruction, a copy of any agreement made or to be made by or among shareholders of the issuer which materially affects, or will materially affect, any of the rights, preferences, privileges, or restrictions of or on securities of the issuer or the management of the issuer (including any voting agreement, irrevocable proxy or shareholders' agreement). Instruction: If a copy of an agreement is not available to the issuer, so state and furnish a brief description of the agreement including therein such information regarding the parties and terms as is known to the issuer. Nothing containe
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