Form D - Application For License For New Hampshire Issuer-Dealer Page 2
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211.Type and amount of securities for which qualification is requested
There are attached hereto and made a part hereof:
(a) Copy of charter, articles of incorporation, or limited liability company, or limited partnership
agreement certified by proper state official.
(b) Copy of by-laws certified by Clerk of the Corporation
(c) Certified copies of Profit and Loss Statement and Balance Sheet as of
last December 31, or close of fiscal year.
(d) Pro-forma Balance Sheet (if new entity with no operating history).
(e) Copy of offering memorandum or prospectus.
(f) Three references as to the business repute and character of applicant,
from unaffiliated persons, including names, addresses, and telephone numbers.
(g) Form D-1, properly executed, by each of the persons signing below.
(h) There is enclosed herewith the fee due on filing this application.
(Corporate seal if incorporated)
THIS APPLICATION MUST BE SIGNED BY ALL THE OFFICERS, PRINCIPALS, DIRECTORS, MANAGERS, MANAGING
AGENTS, OR PARTNERS OF THE CORPORATION OR OTHER LEGAL ENTITY.
(Sign here)
1.___________________________________
5._________________________________________
Date
Date
DOB
SS#
DOB
SS#
2._____________________________________
6._________________________________________
Date
Date
DOB
SS#
DOB
SS#
3._____________________________________
7_________________________________________
Date
Date
DOB
SS#
DOB
SS#
4._____________________________________
8.________________________________________
Date
Date
DOB
SS#
DOB
SS#
STATE OF
COUNTY OF
Subscribed and sworn to before me this
day of
,
_________________________________________
Notary Public
My commission expires
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