Notification Registration Form - Florida (Page 2 of 2) in pdf

Notification Registration Form - Florida Page 2

PART II.

NOTIFIER SHALL FURNISH THE FOLLOWING EXHIBITS: EXHIBITS MAY NOT

BE INCORPORATED BY REFERENCE

Exhibit 1.

One copy of Initial Registration Statement filed with the Securities and Exchange

Commission unless effective with the SEC upon filing with the Office.

Exhibit 2.

Issuer's Consent to Service of Process and Corporate Resolution to be executed

upon Office forms or appropriate Securities and Exchange Commission forms.

Exhibit 3.

One copy of the Final Pricing Amendment/Prospectus.

**For renewal purposes: an issuer need not submit Exhibit 1. A copy of the current prospectus

may be submitted for Exhibit 3.

PART III.

THROUGH EXECUTION OF THIS APPLICATION, NOTIFIER HEREBY AGREES

THAT THE ISSUER OR THE ISSUER'S REPRESENTATIVE WILL:

1. Furnish any other information requested by the Office.

2. Notify the Office by telegraphic notice of effective registration with the SEC within 10

business days of such registration unless effective with the SEC upon filing with the Office.

3. Furnish all documents within 60 days of such registration.

4. Make all sales in Florida through the issuer lawfully registered with the Office as a Dealer

or through any other dealer lawfully registered with the Office.

Signed this

day of

________________________________________

NAME OF NOTIFIER

By:

___________________________________

SIGNATURE, AND OFFICIAL CAPACITY

OR PERSON SIGNING FOR NOTIFIER

STATE OF

)

ss.

COUNTY OF

)

, being duly sworn, deposes and says that he signed the foregoing

notification as

(Official Capacity) of the above-named notifier having full

authority to sign such notification and has examined the exhibits required to be submitted with such

notification and that the information contained therein is true; and that no material fact in answer to the

several questions has been omitted.

Subscribed and sworn to before me

this

day of

NOTARY PUBLIC

(Notarial Seal)

My Commission expires:

Corporation does not have a seal.

NOTE:

THE REGISTRATION PURSUANT TO SECTION 517.082, FLORIDA STATUTES, IS

SUBJECT TO RECEIPT OF ALL DOCUMENTS AS REQUIRED.

ALL OFFERS AND SALES IN FLORIDA MUST BE MADE BY THE ISSUER AS A

REGISTERED FLORIDA DEALER OR OTHER REGISTERED FLORIDA DEALERS.

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

Notification Registration Form - Florida Page 2

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