Form U-1 Or Ct-3 - Application To Register Securities
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4Form U-1 or CT-3
APPLICATION TO REGISTER SECURITIES
Application to the Department of Banking of the State of Connecticut pursuant to The Connecticut Uniform
Securities Act.
For Filing By: (check one) ______ Coordination - Section 36b-17
______ Qualification - Section 36b-18
1. Name and address of Issuer:
Principal office in this State:
2. Name, address and telephone number of correspondent to whom notices and communications regarding this
application may be sent:
3. Name and address of applicant:
4. Registration or acceptance for filing is sought for the following described securities in the amounts indicated:
Offering Price
Total Offering
Offering in this state
Description of
or Proposed
No. of Shares
No. of Shares
Securities
Offering Price
or units
Amount
or units
Amount
$
$
0
0
0
Totals
$
$
0
Indicate the maximum commission to be charged: ________________%
5. Amount of filing fee which is enclosed: $ _____________________
(One-tenth of one percent of the maximum aggregate offering amount in Connecticut:
Minimum $300.00/Maximum $1500.00)
6. A Registration Statement (was filed) (is expected to be filed) with the Securities and Exchange Commission
on _____________________________ and is expected to become effective on or about
(date)
_______________________________.
(date)
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