Form Sc-610-234 - Business Opportunity Application - Securities Division Department Of Financial Institutions

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PO Box 9033
Department of Financial Institutions
Olympia, WA 98507-9033
Securities Division
Phone: 360-902-8760
FAX: 360-586-5068
Business Opportunity Application
(Check only one):
Registration No.
REGISTRATION......... $200
BO-
RENEWAL .................. $125
If assigned
AMENDMENT… … .… .$ 30
I.
Name of applicant
2. Name under which the applicant is doing or intends to do business (d/b/a)
3. Applicant’ s principal business address
Telephone number
FAX Number
4. Person to whom communications regarding this application should be directed:
Name
Firm or Company
Address
Telephone number
FAX Number
I certify under penalty of law that I have read this application and the exhibits attached hereto and incorporated herein by reference, and
know the contents thereof and that the statements therein are true and correct to the best of my knowledge.
Signed this __________ day of __________, 19______. Signature(s) of applicant: ________________________________________
____________________________________________________________
By __________________________________________________________
Title ________________________________________________________
CORPORATE SEAL
(If Applicable)
STATE OF ___________________________________________________
ss.
COUNTY OF _________________________________________________
Personally appeared before me this ________________ day of _______________________________________, 19 __________ the
above-named _________________________________________________ and __________________________________________,
to me known to be the person(s) who executed the foregoing application (as ______________________________________________
_____________________________________________________ the applicant) and (each), being first duly sworn upon oath that said
application and all exhibits submitted herewith, are true and correct.
Notary Public _________________________________________________
NOTARIAL SEAL
SC-610-234 (R/1/95 Page 1 of 3

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