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(Rev. 11/16/1998)
STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 10-2-1
Application for Registration by Qualification
1.
Name of Issuer
Phone
(Street Address)
(City & State)
(Zip Code)
2.
Name of Applicant
Phone
(Street Address)
(City & State)
(Zip Code)
3.
Name of Correspondent
Phone
(Street Address)
(City & State)
(Zip Code)
4.
Agent or Underwriter
Phone
(Street Address)
(City & State)
(Zip Code)
5.
Transfer Agent
Phone
(Street Address)
(City & State)
(Zip Code)
6.
Description of Securities to be offered in Utah
a.
Number of Shares or Units to be offered
b.
Class
c.
Proposed Offering Price per Share or Unit
d.
Amount in Dollars
7.
a.
List the states, other than Utah, in which the issuer or applicant proposes to offer the
securities for sale to the public.
b.
List the states in which the securities are eligible for sale to the public.
8.
Maximum Commission to be paid