Form 209 - Report On Sales Of Securities - Pennsylvania Securities Commission Page 2

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FILE NO.:________________________
FORM 209
EFFECTIVE: 10/11/97
REVISED: 12/23/04
COM M ONW EALTH OF PENNSYLVANIA
PENNSYLVANIA SECURITIES COM M ISSION
PART I
Issuer Information
1.
Exact Name of Issuer: _____________________________________________________________________
2.
Address of Principal Office of Issuer:________________________________________________________
Number and Street
_________________________________________________________________________________________
City
State
Zip Code
Telephone No.
3.
Name and address of person to whom correspondence regarding this filing should be sent:
_________________________________________________________________________________________
Name
Title
Number and Street
_________________________________________________________________________________________
City
State
Zip Code
Telephone No.
PART II Report of Sales of Securities Registered under Section 206.
4.
Date of effectiveness of registration statement under Section 206_______________________________
5.
(A) Offering in Pennsylvania:
(i) Total number of shares or other units: _______________________________________________
(ii) Per share or unit price: ____________________________________________________________
(iii) Maximum aggregate offering price: _________________________________________________
(B) Sales in Pennsylvania:
(i) Number of shares or other units: ___________________________________________________
(ii) Aggregate proceeds received:_______________________________________________________
Each of the persons executing this report on behalf of the Issuer hereby affirms that the statements
made herein, including all attachments hereto, are not incomplete in any material respect or false or
misleading with respect to any m aterial fact. Each of such persons further affirms that he is familiar
with the penalties contained in the Pennsylvania Securities Act of 1972, and all regulations adopted
thereunder for m aking any false or incomplete statement in connection with the sale of a security or in
any filing with the Commission.
IN WITNESS W HEREOF, this report has been executed on ___________________________________.
(insert date)
_______________________________________________
(Name of Issuer)
By: ___________________________________________
(Title)
34

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