Affidavit Regarding Offers Of Ulor Securities Form - Securities Division Of Arizona Corporation Commission

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ARIZONA CORPORATION COMMISSION
SECURITIES DIVISION
AFFIDAVIT REGARDING OFFERS OF ULOR SECURITIES
STATE OF
)
_______________________
) ss
County of ________________________ )
I, ________________________________________, being first duly sworn on oath depose and
say:
I am now a citizen of the United States of America, over the age of twenty-one and competent to
be a witness.
I am a bona fide officer or director of _________________________________________ (the
issuer).
I will provide each person to whom I offer securities with the form “Consumers Guide to Small
Business Investments”, and I will obtain a dated receipt from each such investor. I understand that failure
to comply with this requirement is grounds for revocation or suspension of my license.
I understand that the license for which I am applying only authorizes me to offer and sell securities
on behalf of ______________________________________________ (issuer’s name) and must be done
pursuant to the registration statement on file with the Arizona Corporation Commission, Securities
Division.
Please check one of the boxes below:
I will not be receiving sales related compensation for the sale of the ULOR securities.
I will be receiving sales related compensation for the sale of the ULOR securities.
____________________________________________________
SUBSCRIBED and SWORN to before me this __________day of
______________________, 2004.
____________________________________________________
Notary Public in and for the state of ____________residing at
____________________________________________________
5/04

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