Psc/form Ro - Request For Waiver Of Procedures Page 3
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5PSC/FORM RO
EFFECTIVE: 7/7/90
REVISED: 1/1/00
COM M ONW EALTH OF PENNSYLVANIA
PENNSYLVANIA SECURITIES COMM ISSION
Request for W aiver of Procedures under Regulation 504.060(b)
"RESCISSION OFFERS"
1.
Exact Name of Offeror:____________________________________________________________________
2.
Address of Principal Office of Offeror:______________________________________________________
Number and Street
_________________________________________________________________________________________
City
State
Zip Code
Telephone No.
3.
Name and address of person to whom correspondence on this filing should be sent:
_________________________________________________________________________________________
Name
Title
Number and Street
_________________________________________________________________________________________
City
State
Zip Code
Telephone No.
4.
(A) Legal Form of Offeror (Corporation, Partnership, Individual, etc.):_________________________
(B)
If Offeror not an individual, designate state of incorporation or formation:__________________
(C)
State the names and addresses of the general partner, promoter, and chief executive officer, chief
operating officer and chief financial officer of the Offeror.
Complete (D) through (F) only if Offeror is the Issuer.
(D) If anyone in (C) has held a similar position with another person (not the Issuer) which made a
rescission offer in Pennsylvania within the past 5 years, state the name of the person and date of
the rescission offer. If none, so state.
(E)
Has the Issuer made a rescission offer in Pennsylvania within the last 5 years?
YES
NO
[ ]
[ ]
(F)
Does the Issuer plan to continue offering securities for sale in Pennsylvania which are the subject
of the rescission offer? If yes, upon which section of the Act will the Issuer rely?
YES
NO
[ ]
[ ]
5.
Has the general partner, promoter, chief executive officer, chief operating officer,chief financial officer
or owner of 20% or more of any class of securities of the Issuer been convicted of any crime or made
the subject of any sanction or otherwise found to have met any of the criteria described in Section
305(a)(ii)-(ix) of the Act?
If yes, describe fully.
YES
NO
[ ]
[ ]
6.
(A) Describe the type and price per unit of securities subject to the rescission offer.
(B)
For each sale of securities covered by this rescission offer, provide in columnar form the name and
address of each Pennsylvania purchaser, the date of sale, and the dollar amount of securities
purchased.
7.
(A) Provide the name and address of the person who effected the transactions which are now the
subject of the rescission offer.
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