Application To Register Securities Form - 2013 Page 3
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7Application to register securities — continued from previous page
7. Broker-dealer or salespersons: Name, address, and telephone number of the broker-dealer licensed in Oregon and
lead broker-dealer, if any.
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
Is this broker-dealer a member of NASD?
Yes
No
If licensing a salesperson to the issuer in lieu of using a broker-dealer or employing a salesperson who is already
licensed in Oregon, list the salesperson’s name, address, Social Security number, and CRD number, if applicable.
If licensing a salesperson to the issuer, submit Form U-4 and $50 fee with this application. If claiming an exclusion
from licensing under OAR 441-175-0040, so indicate.
Name:
Phone:
(
)
Address:
SSN:
City:
State:
ZIP:
CRD no.:
Claiming exclusion from licensing under OAR 441-175-0040?
Yes
No
Form U-4 and $50 fee enclosed?
Yes
No
Note: An order of registration will be issued only when licensing of the issuer salespersons, if required, is completed.
8. Professionals involved: Provide the names, addresses, and telephone numbers of all professionals who have rendered
service or have given advice in connection with this offering if they are named as experts in your sales literature or
presentations or whose names are used to give authority to statements made concerning this offering. Describe their
scope of activities. Include attorneys, accountants, appraisers, engineers, etc.
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
Attorney
Accountant
Appraiser
Engineer
Other (specify):
Scope of activities:
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
Attorney
Accountant
Appraiser
Engineer
Other (specify):
Scope of activities:
Name:
Phone:
(
)
Address:
City:
State:
ZIP:
Attorney
Accountant
Appraiser
Engineer
Other (specify):
Scope of activities:
Page 3 of 7
440-2013 (6/06/COM/WEB)
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