Registration By Qualification Form - Washington Department Of Financial Institutions
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1
2STATE OF WASHINGTON
Department of Financial Institutions
Securities Division
PO Box 9033
Olympia, WA 98507-9033
360-902-8760
REGISTRATION BY QUALIFICATION
1. Name and address of registrant ____________________________________________________________________
2. Name and address of issuer _______________________________________________________________________
______________________________________________________________________________________________
3. Short description of securities to be qualified:
4. Number of securities to be offered in Washington ______________________________________________________
5. Number of securities to be offered in all states ________________________________________________________
6. Maximum price per security _______________________________________________________________________
7. Fee ($100.00 for the first $100,000 of initial issue, or portion thereof in this state, based on the offering price,
plus 1/20 of 1% for any excess over $100,000 which are to be offered during that year.)
______________________________________________________________________________________________
(NOT LESS THAN $100.00)
8. Fiscal year ends ________________________________________________________________________________
9. Name, address, and phone number of person to contact who is responsible for this filing _______________________
______________________________________________________________________________________________
_____________________________________________
By: _____________________________________________
STATE OF WASHINGTON
County of ______________
_____________________________________________________________, being first sworn, deposes and says: I have
been authorized by the registrant to execute and file the foregoing statement. I have read the statement and the exhibits
filed with it, and the facts stated in the statement and in the exhibits are true to the best of my knowledge, information
and belief.
_____________________________________________
AFFIANT
Subscribed and sworn to before me
this ________ day of __________, 19 ____
_____________________________________________
NOTARY PUBLIC
SC-610-004 REG. BY QUALIFICATION (R/5/91)M Page 1 of 3
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