Application To Register Securities Form - 2013
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7Oregon Department of Consumer & Business Services
Division of Finance & Corporate Securities
350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
(503) 378-4140 Fax: (503) 947-7862 TTY: (503) 378-4100
dfcs.oregon.gov
APPLICATION TO REGISTER SECURITIES
Pursuant to OAR 441-065-0220, 0230
Check one:
Initial
Amendment
Renewal of no.:
Instructions: Use this form for registering offerings under OAR 441. Attach pages if space is insufficient. Offerings
registered pursuant to OAR 441-065-0220 must submit the offering document. Offerings registered pursuant to OAR 441-
065-0230 do not require submission of documents unless requested by the Department of Consumer and Business
Services.
1. Fees: 1/10 of 1 percent of the amount being offered in Oregon.
Minimum fee, $200; maximum fee, $1,500. (Fees are not prorated or refundable.)
Registration fee:
$
Number of issuer salespeople:
x $50 =
$
Total fees enclosed:
$
2. Issuer name by which offering is to be known: Name, address, and telephone number of issuer, or issuer to be
formed, and principal offices, if any, in this state. (Where required, issuer must file appropriate name reservation or
organizational documents before an order may be issued pursuant to this application.)
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
3. Correspondent: Name, address, and telephone number of attorney or any other correspondent to whom
communications regarding this application should be sent:
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
Continued on next page
Make check or money order payable to Oregon
Mail application with payment to:
Department of Consumer & Business Services. If paying
DCBS Fiscal Services
by credit card, applicant must sign credit card information
P.O. Box 14610
box. Do not fax; do not send cash.
Salem, OR 97309-0405
Fiscal use only: 62110/1008
Visa
MasterCard
Discover
Phone:
(
)
/
Credit card number
Expiration
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
440-2013 (6/06/COM/WEB)
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