Form Sr-3 - Midwest Regional Review Application printable pdf download

Robin Carnahan

Secretary of State

State of Missouri

Securities Division • 600 W. Main • PO Box 1276

Jefferson City, MO 65102

MIDWEST REGIONAL REVIEW APPLICATION

Name of Issuer: ___________________________________________________________________________

Fax number: ________________________________ E-Mail Address: ________________________________

The issuer (“applicant”) is filing for Coordinated Midwest Regional Review in the following states

(please check all that apply; at least two must be checked):

_______ Illinois

________ Minnesota

________ North Dakota

_______ Indiana

________ Michigan

_________ South Dakota

_______ Iowa

________ Missouri

_________ Wisconsin

_______ Kansas

________ Nebraska

The applicant shall send to each state, a copy of this Application, accompanied by the exhibits (See

Appendix A) and the fees required by that state (see Appendix B). These filings shall be made

simultaneously in each state as checked in Item 2 above. The documents filed in each state shall be

identical. (Note: Subsequent to the initial filing for Midwest Regional Review, the issuer may file a new

application in at least two of the remaining participating states, but will then be subject to a new

coordinated review.)

Type of filing (please check one):

_________ Small Company Offering Registration (SCOR Form U-7)

_________ Question/Answer Form Model A under Regulation A

_________ Offering Circular Model B under Regulation A Form 1-A (Traditional Disclosure)

Undertakings of Applicant:

The applicant agrees that it will file simultaneously in each state checked above.

The applicant waives automatic effectiveness in each state checked above.

The applicant agrees to resolve outstanding comments through the lead state and agrees to provide the

lead state with a copy of the amended offering document marked to show changes. (Note: State-specific

comments must be resolved with the state to which the comment applies.)

The applicant understands that the securities to be registered must be sold by an agent that is either

registered or exempt from registration in the subject state. The applicant agrees not to allow sales by

agents that have not been registered or are not exempt in the state in which they are selling.

The applicant agrees to file all final documents with each state.

Applicant Representative:

_______________________________________

Signature & Date

_______________________________________

Print Name & Title

FORM SR-3 (01-05)

Form Sr-3 - Midwest Regional Review Application

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