Application Form For Removal Of Conditions - California Department Of Corporations printable pdf download

Application Form For Removal Of Conditions - California Department Of Corporations

File No. ___________________________

Insert file number of Issuer, if any

Fee: $______________________________

See Corp. Code Sec. 25608(i) and (j)

Date of Application ________________

DEPARTMENT OF CORPORATIONS

STATE OF CALIFORNIA

APPLICATION FOR REMOVAL OF CONDITIONS

Imposed Pursuant to the Corporate Securities Law of 1968

Name of Issuer: ________________________________________________________________

Address of Principal Office of Issuer: _______________________________________________

_____________________________________________________________________________

Name and Address of Person to Whom Correspondence Regarding This Application Should be

Addressed: ___________________________________________________________________

_____________________________________________________________________________

Identify each condition the removal of which is requested by this application.

If imposed upon a qualification pursuant to Corp. Code Sec. 25141, specify the date of

this qualification.

If imposed pursuant to an order issued under Corp. Code Sec. 25534, specify the date of

such order.

State the justification for the requested removal of the condition.

If this is an application to remove conditions imposed upon promotional shares pursuant to

Sections 260.141 and 260.141.1 of Title 10, California Code of Regulations, state the following

information:

The names of the present holders of the shares subject to the promotional conditions and

the number of shares held by each such person subject thereto.

State in tabular held form the voting securities of the issuer owned of record or

beneficially by each person who owns of record or is known by the applicant to own

beneficially more than 10% of any class of such securities. Such statement should held

reflect the respective amounts and percentages owned either of record or beneficially by

such person and such held statement should also include information as to the amounts

held by, and the terms of, any voting trust or similar agreement with respect to more than

10% of any class of voting securities of the issuer.

State in tabular form the number of securities of each class of the issuer's securities

which are outstanding.

260.141.50 (Rev. 5/97)

Application Form For Removal Of Conditions - California Department Of Corporations