Form 8 - Application To Offer Or Sell Securities - 2007

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SECURITIES AND BUSINESS REGULATION
2 Martin Luther King, Jr. Drive, S.E.
Ste 802, West Tower
Atlanta, Georgia 30334
(404) 656-3920
ROBERT D. TERRY
KAREN HANDEL
Commissioner of Securities
APPLICATION TO OFFER OR SELL SECURITIES FORM 8 Georgia
Assistant Commissioner of Securities
Securities Act of 1973, as amended O.C.G.A. §§10-5-5 and 10-5-9
Name of Issuer:
A. Types of Filings and Fees
Check
Amount
One
Type
Required Fee
Enclosed
1/20 of 1% aggregate offering (Minimum $250)
Registration by Qualification - O.C.G.A. §10-5-5(b)
1/20 of 1% aggregate offering (Minimum $250)
Registration by Notification - O.C.G.A. §10-5-5(d)
1/20 of 1% aggregate offering (Minimum $250)
Small Issue Registrant - O.C.G.A. §10-5-5(e)
$250 (Nonrefundable) (Use Form U-1)
SEC Coordinated Filing Exemption - O.C.G.A. §10-5-9(5)
$250 (Nonrefundable) (Use Form D)
Uniform Limited Offering Exemption - O.C.G.A. §10-5-9(16)
$100 (Nonrefundable)
Renewals - O.C.G.A. §§10-5-5(b), (d) & (e); O.C.G.A. §§10-5-9(5) & (16)
None Required
Nonprofit Issuer Registration - O.C.G.A. §10-5-5(f)
None Required
Renewal - O.C.G.A. §10-5-5(f)
(Please make all checks payable to: COMMISSIONER OF SECURITIES, STATE OF GEORGIA)
B. General Information
1. Name & Address of Issuer:
Name
Phone Number
Address
City
State
Zip
2. Name, Address and Phone Number of Correspondent to whom notices and communications regarding this application may be sent:
Name
Phone Number
Address
City
State
Zip
3. Name and Address of the Applicant:
Name
Phone Number
Address
City
State
Zip
4. Registration or acceptance for filing is sought for the following described securities:
Total Offering
Offering in Georgia
Description Of
Offering Price Or
Number Of Shares
Amount
Number of Shares
Amount
Securities
Proposed Offering
Or Units
Or Units
Price
1
Form 8 Rev. 1/2007

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