Prior Form To Making An Offer Of Securities Inthis State, File This Notice In The Los Angeles Office Of The Department Of Corporations - State Of California Department Of Corporations

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(Department of Corporations Use Only)
Fee paid $________________
Receipt No. ______________
FEE: $2,500 (Corporations Code Section 25608.1(c))
STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS
NOTICE PURSUANT TO
CORPORATIONS CODE SECTION 25102.1(c)
PRIOR TO MAKING AN OFFER OF SECURITIES IN THIS STATE, FILE THIS
NOTICE IN THE LOS ANGELES OFFICE OF
THE DEPARTMENT OF CORPORATIONS
1. A. Name of Issuer: ____________________________________________
B. State or other jurisdiction in which incorporated or organized:
_________________________________________________
2. A. Description of Securities: _________________________________
Total number of securities being offered in California: _______________
Proposed maximum dollar amount to be raised in California: $ _____________
B. The issuer will, upon request of the Commissioner of Corporations, file with the Department of Corporations any
document filed with the Securities and Exchange Commission in any annual or periodic report.
____ YES _____ NO
3. A consent to service of process (Corporations Code Section 25165 and Rule 260.165) is: _____ attached; or _____ already on
file with the Commissioner of Corporations.
4. A. Name of person filing this notice: ____________________________________________________________
B. Address of person filing this notice:
____________________________________________________________
5. I certify (or declare) under penalty of perjury under the laws of the State of California that the statements herein are true and
correct.
Executed at [Place]________________________________ on[Date]_________________
________________________________________
Signature
________________________________________
Typed or Printed Name of Person Signing
________________________________________
Title
• Securities • Franchises • Off-Exchange Commodities • Investment and Financial Services •
• Independent Escrows • Consumer and Commercial Finance Lending • Residential Mortgage Lending •

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