Form D - Application For License For New Hampshire Issuer-Dealer
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2New Hampshire Form D
No. ____________________________
STATE OF NEW HAMPSHIRE
Rec'd __________________________
DEPARTMENT OF STATE
App'd __________________________
BUREAU OF SECURITIES REGULATION Fee ____________________________
Granted ________________________
Application for License for New Hampshire Issuer-Dealer
To the Secretary of State
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.
(a) Type of Organization:
Corporation
Partnership/LLP
Proprietorship
Other
LLC
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.
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