Statement Of Issuer - Minnesota Department Of Commerce
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1
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3SAMPLE FORM:
MUST BE RETYPED
STATEMENT OF ISSUER
Minn. Stat. § 80A.15, Subd. 2 (h)
$50.00 Fee Required
This form is to be prepared and filed pursuant to Minnesota Statutes, 1980,
Section 80A.15, Subd. 2 (h) and mailed to:
STATE OF MINNESOTA
DEPARTMENT OF COMMERCE
85 7th PLACE EAST
ST
PAUL,
MINNESOTA
55101
1.
State the name and address of the issuer, and date and state of
organization.
2.
If the issuer is a foreign corporation, state the name and address of the
agent within Minnesota upon whom service of process may be obtained.
3.
State the name, address, telephone, and position held by the person to whom
inquiries pertaining to information herein or notice of objection by the
Commissioner of Commerce should be directed.
4.
State the nature of the business enterprise or enterprises engaged in by the
issuer.
5.
State whether the issuer of these securities has, within the past five
years, made application to register any of its securities with the Minnesota
Department of Commerce.
Yes ______
No ______
6.
State the aggregate dollar amount, number of units, price per unit, and set
forth a description of the securities to be sold.
Set forth the minimum
dollar amount which may be purchased by any individual or corporation.
7.
State whether commissions will or will not be paid.
If commissions are to
be paid, indicate the amount of such commissions in dollar amount and as a
percentage of the offering price, and identify the persons to whom they will
be paid.
8.
State the date on which it is proposed to commence the sale of these
securities.
9.
State the date by which it is proposed to terminate the offering.
10.
The issuer proposes to make sales to not more than ______ persons in the
State of Minnesota.
11.
With reference to sales of securities made within a six-month period
preceding the proposed date of the distribution described herein, state the
number of sales, the dollar amount paid, the number of shares issued, and
the dates of said sales.
If exemption for the sale of said securities is
claimed, designate the exemption relied upon with specific reference to
Minnesota statutes.
12.
The issuer, through its authorized agent whose signature appears below,
certifies that:
a)
The information contained in this Statement of Issuer and the Exhibits
appended hereto are accurate and complete to the best knowledge and
belief of the undersigned.
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