Notification Registration Form - Florida printable pdf download

Notification Registration Form - Florida

FILE NO. ________________

VAL. NO. ________________

AMT.

DATE ______

FOR OFFICE USE ONLY

STATE OF FLORIDA

OFFICE OF FINANCIAL REGULATION

NOTIFICATION REGISTRATION - SECTION 517.082, FLORIDA STATUTES

(Notification may be made by the issuer, by a registered dealer, by any person on whose behalf the offering

is to be made, or by a duly authorized agent of such person.)

NOTE: The general information required on this form must be supplied by every notifier. A

fee of $1,000 shall accompany every application for registration.

Checks should be

payable to: Department of Financial Services.

NOTICE:

THIS FORM IS TO BE USED ONLY WHERE A REGISTRATION STATEMENT COVERING THE

SECURITIES AND OFFERING DESCRIBED HEREIN HAS BEEN FILED WITH THE SECURITIES

AND

EXCHANGE

COMMISSION

AND

THERE

PROHIBITION

FROM

REGISTRATION UNDER SECTION 517.082(3), FLORIDA STATUTES.

PART I.

GENERAL INFORMATION

Item 1.

Name and address of the issuer and principal office.

Federal

Employer

Identification

(FEID)

Number:

Item 2.

Name, address and telephone number of correspondent to whom notice and

communications regarding this notification may be sent.

Item 3.

Name and address of notifier.

Item 4.

Issuer organized under the laws of

Date:

______________

Item 5.

Notification Registration under Section 517.082, Florida Statutes, is made for the

securities to be effectively registered under

SEC Reg. No. ___________________

OFR-S-3-91, REVISED 5-01-2004

Notification Registration Form - Florida

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