Form D-1 Application For License For New Hampshire Issuer-Dealer - State Of New Hampshire

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State of New Hampshire
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Form D-1
Department of State
Bureau of Securities Regulation
No.
Rec'd
App'd
Fee
Granted
Application for License for New Hampshire Issuer-Dealer
The undersigned hereby applies for a license authorizing it to sell its securities in this state under the New
Hampshire Blue Sky Law and makes the following statement:
1. Name of applicant
2. Address of applicant
3. Telephone No.
4. Date of incorporation or organization, and place:
5. Type of Organization:
Corporation
Partnership/LLP
LLC
Proprietorship
Other
Yes
6. Are you actually engaged in business in this state?
7. Give the names, residences, business addresses, capacity and title of all persons interested in the business as
principals, officers, directors, managers or managing agents.
Name
Residence
Business Address
Capacity and Title
8. In what other states have you ever applied for a securities license?
9. In what other state are you licensed or registered?
10. State briefly the general plan and character of the business of applicant, specifying the nature of property in
which it is proposed to deal, and the method of transacting business, whether by solicitation, advertisement,
correspondence or otherwise.
11. Type and amount of securities for which qualification is requested
12. Date and month of end of fiscal year

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