Application To Register Securities Form - 2013 Page 5
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7Application to register securities — continued from previous page
9. Business plan: Describe the nature of the business to be conducted with the proceeds of the offering.
10. Use of proceeds:
Dollars
Percent
Minimum
Maximum
Minimum
Maximum
Selling commissions
$
$
%
%
Other selling expenses
$
$
%
%
Legal, accounting, printing, and filing fees
$
$
%
%
Offerer/promoter compensation
$
$
%
%
Reserves
$
$
%
%
Remaining funds will be used as follows:
$
$
%
%
$
$
%
%
$
$
%
%
Total:
$
$
%
%
Is a proceeds escrow established or needed for this offering? See OAR 441-065-0150.
Yes
No
If yes, are you requesting a waiver of the escrow requirement? See OAR 441-065-150(4).
Yes
No If yes, attach justification.
11. Integration: (See OAR 441-065-0090 about elements of integration.) Were any securities of the issuer sold within
the six months preceding the effective date of this registration?
Yes
No
If yes, show how many “counting purchasers” were involved during the year preceding this registration and include
dates of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Counting purchaser:
Date of sale:
Note: Securities issued pursuant to certain employee benefit plans are excluded. See OAR 441-065-0090(2).
Page 5 of 7
440-2013 (6/06/COM/WEB)
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