Form Njbos-19 - Request For Waiver Of Exemption Conditions (Page 3 of 3) in pdf

Form Njbos-19 - Request For Waiver Of Exemption Conditions Page 3

Request for Waiver of Exemption Conditions

Page 3

8. Has offeror or its affiliates or agents made any offers of these

securities in New Jersey within 12 months prior to this offering?

Yes ____ No_____

If so, please provide the following information:

Name and Address of Offeree

Date

Dollar Amount

_______________________________________

________________ ____________

_______________________________________

________________ ____________

_______________________________________

________________ ____________

_______________________________________

________________ ____________

9. Request for waiver:

a. Applicant requests waiver of investment intent condition,

Yes ____ No ____

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

b. Applicant requests waiver of commission condition,

Yes ____ No ____

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

c. Applicant requests increase in number of buyers from

Yes ____ No ____

10 to _____ (not more than 20 during a 12-month period).

I certify that the foregoing statements made by me are true. I am aware that if any of the fore-

going statements made by me are willfully false, I am subject to punishment.

__________________________________

Name of offeror

By: _______________________________

Title: ______________________________

Date: ______________________________

Phone: ____________________________

Fax: ______________________________

Form NJBOS-19

8/03

Form Njbos-19 - Request For Waiver Of Exemption Conditions Page 3