Registration For Resale Or Dealing And Trading {440-2203} | Pdf Fpdf Doc Docx | Oregon

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Registration For Resale Or Dealing And Trading {440-2203} | Pdf Fpdf Doc Docx | Oregon

Registration For Resale Or Dealing And Trading {440-2203}

This is a Oregon form that can be used for Securities within Secretary Of State, Blue Sky.

Alternate TextLast updated: 7/19/2011

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Oregon Department of Consumer and Business Services Division of Finance and Corporate Securities 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 503-378-4140 Fax: 503-947-7862 http://dfcs.oregon.gov REGISTRATION FOR RESALE, OR DEALING AND TRADING ORS 59.035(9), OAR 441-065-0040 I. Identity of the broker/dealer applicant: 1. Name of applicant: 2. Street address of principal executive office of the applicant: City: 3. Applicant's phone number: 4. Chief executive officer of the applicant: 5. Title and class of security to be registered: : State: ZIP: CRD number: 6. Par or stated value of security to be registered: 7. Were the securities the applicant is seeking to register acquired in the ordinary and usual course of business by the No Yes applicant and are not part of an unsold allotment or an attempt to evade the Oregon Securities Law? 8. Please attach a separate statement describing the reasons why the exemption is being sought. 9. Is the registration being submitted directly or indirectly on behalf of: The issuer? Yes No Yes Yes No Yes No No Any director of the issuer? Any officer of the issuer? Any controlling person of the issuer? The beneficial owner of more than 10 percent of the outstanding units or shares of any equity security of No Yes the issuer? 10. Is the applicant or any associated person affiliated directly or indirectly with the issuer? 11. Is the registration being sought directly or indirectly for the benefit of another broker-dealer? If yes, please state the name of the broker-dealer: Continued Visa MasterCard Discover Phone: Expiration date Yes No Make check or money order payable to Department of Consumer and Business Services. Mail application with payment to: DCBS -- Fiscal Services P.O. Box 14610 Salem, OR 97309-0445 Fiscal use only: 62110-1008 Credit card number Name of cardholder as shown on credit card $ Cardholder signature Amount Secure fax for credit card payments: 503-947-2333 If paying by credit card, the applicant must sign the credit-card information box. 440-2203 (2/11/COM) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com II. Identity and background of the issuer: 12. Name of issuer: 13. Street address of principal executive office of the issuer: City: 14. Chief executive officer of the issuer: 15. Issuer's phone number: 16. State of incorporation: 17. Is the issuer organized under the laws of the United States or any state as defined in ORS 174.100? 18. Type of organization: 19. Names and addresses of each of the issuer's current officers (attach additional sheets, if necessary): Yes No State: ZIP: 20. Names and addresses of each of the issuer's current directors (attach additional sheets, if necessary): 21. Name and address of any officer or director that has held office within the past five years (attach additional sheets, if necessary): 22. Number of employees on a recent date: Specify the date: 23. To the best of the applicant's knowledge, has the issuer, any executive officer, director, or general partner of the issuer within the past five years of the date of this application: · Been the subject of an administrative order issued by the director of the Department of Consumer and Business Services (DCBS) for violation of any provision of the Oregon Securities Law or any rule or order of the director? Yes No · Been or is engaged in dishonest or fraudulent conduct with regard to securities? Yes No · Been convicted of a misdemeanor, an essential element of which is fraud? Yes No · Been convicted of a felony? Yes No Continued 440-2203 (2/11/COM) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Made or caused to be made to the director any false representations of a material fact or has suppressed or withheld from the director any material information? Yes No · Refused to permit an examination to be made by the director of DCBS or failed to file any report, including any financial report, or furnish any information required by the director in connection with the Oregon Securities Law? Yes No · Been the subject to any order entered by a governmental agency or self-regulatory organization prohibiting or suspending the person from engaging in or continuing any conduct or practice involving any aspect of the securities business? Yes No · Been subject to any judgment or decree of any court of competent jurisdiction, which is based on either securities violations or fraud? Yes No If the answer to any of these questions is "yes," give details in an attached statement. Include an identification of the jurisdiction, relevant dates, charge, and disposition of the matter. · 24. Name and location of each subsidiary of the issuer (attach additional sheets, if necessary): 25. Describe the nature of products or services offered by the issuer (attach additional sheets, if necessary): 26. Describe the nature and extent of the issuer's facilities (attach additional sheets, if necessary): 27. Describe the history of the issuer, including dates of consolidations, mergers, or spinoffs. Give names of companies, partnerships, etc. involved (attach additional sheets, if necessary): Continued 440-2203 (2/11/COM) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com III. Description of issuer's securities: 28. Number of shares or total amount of the securities outstanding as of the end of the issuer's most recent fiscal year: Number of shares or units eligible for secondary trading without the benefit of registration under the Securities Act of 1933: 29. Has the issuer made an offer, except to employees, of the same class of securities sought to be registered in the past six months? Yes No 30. Dates of securities issued in a public offering, if any (attach additional sheets, if necessary): States in which those securities were issued: Number of shares: Price per share (adjusted to reflect present capitalization): Net proceeds to the issuer: Name and address of the underwriter: Attach copies of the latest prospectus, annual report, and proxy statement for the securities. 31. Disclose all facts pertaining to the issuance of securities in transactions other than those described in No. 30. Include a description of warrants and options that have been granted but not yet authorized. 32. The issuer had Number of stockholders on Recent date . 33. Number of people domiciled in the United States who beneficially own more than 10 percent or more of the outstanding securities of the security sought to be registere

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