Form Fis 0530 Application To Register Securities By Qualification printable pdf download

Form Fis 0530 Application To Register Securities By Qualification

FIS 0530 (5/04) Office of Financial and Insurance Services

Application to Register Securities By Qualification

This form is to be used for filing by Qualification pursuant to Section 304 and must be used for offerings made pursuant

to the Regulation A exemption under the Federal Securities Act of 1933.

Issuer Information:

Name

Address (number, street, city, state, zip code)

Principal Office in this State

Organization Information:

Form

State

Date Organized/Incorporated

Notices and communications regarding this application may be sent to:

Name

Phone

(

)

Address (number, street, city, state, zip code)

Name and address of applicant if different from Issuer:

Name

Address (number, street, city, state, zip code)

Indicate Status:

Broker-Dealer

Selling Shareholder

Registration is sought for the following described securities in the amounts indicated

Offering Price or

Total Offering

Offering in this State

Proposed

Number of Shares

Description of Securities

Offering Price

Or Units

Amount

Or Units

Amount

Total

Indicate maximum commission to be charged:

Amount of fee enclosed $

(fee is $1.00 per $1,000 aggregate sale price, minimum $100,

maximum $1,250. Make checks payable to “State of Michigan.”

RETURN COMPLETED APPLICATION TO:

This form is issued under Act 265, PA 1964, as amended.

You must complete & submit this form if you wish to make

an application for registration under Section 304 of the

Act.

Office of Financial and Insurance Services

Securities Section

P.O. Box 30701

Lansing, MI 48909-8201

Form Fis 0530 Application To Register Securities By Qualification

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