Form S-3 - Registration Statement For Registration Of Securities By Qualification (2013) Page 2

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Form S-3
Rev. 03/13
COMMONWEALTH OF PUERTO RICO
COMMISSIONER OF FINANCIAL INSTITUTIONS
Securities Regulation Division
Fernandez Juncos Station
PO Box 11855
San Juan, PR 00910-3855
Tel. (787) 723-3131 Fax (787) 724-2604
REGISTRATION STATEMENT
FOR REGISTRATION OF SECURITIES BY QUALIFICATION
INSTRUCTIONS
This form may be filed by the issuer, any other person on whose behalf the offering is to be made,
or a registered broker-dealer.
1.
(a)
Name and address of applicant _______________________________________
_______________________________________________________________________
(b)
Name, address and telephone number of person with whom the Securities Regulation
Division is requested to communicate regarding the filing ________________
_______________________________________________________________________
2.
State whether applicant is the issuer, or a broker-dealer registered in Puerto Rico or other person
on whose behalf the securities will be offered:
________________________________________________________________________
_______________________________________________________________________
3.
(a)
Name and address of issuer:__________________________________________
_______________________________________________________________________
(b)
Name and address of any significant subsidiary:__________________________
_______________________________________________________________________
4.
Name and address of any person on whose behalf any part of the offering is to be made in a non-
issuer distribution: ________________________________________________________
________________________________________________________________________
Description of the securities being registered: _________________________________
5.
________________________________________________________________________

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