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(Rev. 11/16/98)
STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 14-25s
Accredited Investor Exemption
Uniform Notice of Transaction
Notice of Sale of Securities pursuant to Accredited Investor Exemption
1. Issuer:
Name:
Address:
Telephone Number:
2. Form of Organization: (check one)
9Corporation
9Unincorporated Association
9Limited Liability Company
9Limited Partnership
9Other (specify) ______________________________________
Issuer’s state or jurisdiction of Incorporation or Organization: ______________________
Date of Incorporation or Organization: ________________________________________
3. Officers and Directors: (or persons acting in a similar capacity)
Names, Business Addresses, and Business Phone Numbers
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________
4. This Offering:
Description of
Price per
Number of Securities
Aggregate dollar
Security
Security
to be Offered
Amount of Offering
Debt
Equity (Common or
Preferred)
Convertible Security
Partnership Interests
Other (Specify)