Form Njbos-19 - Request For Waiver Of Exemption Conditions printable pdf download

Form Njbos-19 - Request For Waiver Of Exemption Conditions

NEW JERSEY BUREAU OF SECURITIES

153 Halsey Street, 6

Floor

Newark, New Jersey 07102

REQUEST FOR WAIVER OF EXEMPTION CONDITIONS

Pursuant to N.J.S.A. 49:3-50(b)(9)

Instructions: This form should be filed to request a waiver of one or more of the conditions under

N.J.S.A. 49:3-50(b)(9). Please answer all questions and furnish all required exhibits. There is

no fee for this application.

____________________________________________________________________________

Based on the following information, the undersigned requests a waiver of one or more of the

conditions under N.J.S.A. 49:3-50(b)(9).

1. Offeror of securities:

a. Name: ___________________________________________________________________

b. Address: _________________________________________________________________

c. Relationship to issuer: ______________________________________________________

d. Is offeror of securities a broker-dealer?

Yes ____ No ____

e. If offeror of securities is a broker-dealer, is it registered

Yes ____ No ____

with the Bureau?

2. Issuer of securities:

a. Form of entity: Corp. ___ LLC ___ Business trust ___ Other (specify)_________________

b. Name: ___________________________________________________________________

c. Address: _________________________________________________________________

d. State of formation: ______________________________ Date: _____________________

3. Securities to be sold:

a. Title of securities offered: ___________________________________________________

b. Dollar amount to be sold in New Jersey: $_______________________________________

c. Number of units to be sold in New Jersey: ______________________________________

Form Njbos-19 - Request For Waiver Of Exemption Conditions