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Application For Removal Of Conditions 260.141.50 - California
|Application For Removal Of Conditions Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .||
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File No. ___________________________ Insert file number of Issuer, if any Fee: $______________________________ See Corp. Code Sec. 25608(i) and (j) Date of Application ________________ DEPARTMENT OF CORPORATIONS STATE OF CALIFORNIA APPLICATION FOR REMOVAL OF CONDITIONS Imposed Pursuant to the Corporate Securities Law of 1968 1. 2. 3. Name of Issuer: ________________________________________________________________ Address of Principal Office of Issuer: _______________________________________________ _____________________________________________________________________________ Name and Address of Person to Whom Correspondence Regarding This Application Should be Addressed: ___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Identify each condition the removal of which is requested by this application. a. b. If imposed upon a qualification pursuant to Corp. Code Sec. 25141, specify the date of this qualification. If imposed pursuant to an order issued under Corp. Code Sec. 25534, specify the date of such order. 4. 5. 6. State the justification for the requested removal of the condition. If this is an application to remove conditions imposed upon promotional shares pursuant to Sections 260.141 and 260.141.1 of Title 10, California Code of Regulations, state the following information: a. b. The names of the present holders of the shares subject to the promotional conditions and the number of shares held by each such person subject thereto. State in tabular held form the voting securities of the issuer owned of record or beneficially by each person who owns of record or is known by the applicant to own beneficially more than 10% of any class of such securities. Such statement should held reflect the respective amounts and percentages owned either of record or beneficially by such person and such held statement should also include information as to the amounts held by, and the terms of, any voting trust or similar agreement with respect to more than 10% of any class of voting securities of the issuer. State in tabular form the number of securities of each class of the issuer's securities which are outstanding. c. 260.141.50 (Rev. 5/97) 1 2001 © American LegalNet, Inc. 7. If this is an application for the removal of a restriction on transfer imposed by the Commissioner or for the removal of promotional conditions, state in tabular form the title and amount of securities called for by any options, warrants or rights, including the purchase price of the securities so called for and the expiration dates of such options, together with the market value of the securities so called for as of the latest practicable date. Such statement should include the foregoing information for all options held by each officer or director of the issuer. If this is an application for the removal of an impound condition, furnish the information indicated by Section 260.141.24, Title 10, California Code of Regulations. There are attached hereto as exhibits the following which are incorporated by reference: a. Financial statements of the issuer as required by Section 260.613, Title 10, California Code of Regulations. Copies (which may be in a restated or composite form) of the issuer's current charter documents (as defined in Section 260.001, Title 10, California Code of Regulations). 8. 9. b. 10. The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized. ___________________________________ Applicant By ________________________________ ___________________________________ (Title) I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits thereto and know the contents thereof, and that the statements therein are true and correct. Executed at _____________________ on __________________. (Place) (Date) ___________________________________ (Signature) Instruction: The application may be made and signed either by the issuer or by the holders of the shares upon which the conditions are imposed. 2 2001 © American LegalNet, Inc.