Form U-1 Or Ct-3 - Application To Register Securities Page 4
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4_________________________________________________________________________________________________
FOR AN ACKNOWLEDGMENT OF THE FILING
OF THIS APPLICATION COMPLETE THE LEFT COLUMN BELOW
_________________________________________________________________________________________
Name and address of correspondent
State of _____________________________
_______________________________________
_______________________________________
File Number _________________________
_______________________________________
Applicant
Date _______________________________
_______________________________________
Examiner ___________________________
Issuer
_______________________________________
Telephone __________________________
Name of any broker-dealer or agent of issuer registered to do business under this chapter who may offer the
securities in this state:
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Parent category: Legal