Form Njbos-6 - Registration Statement For Registration By Notification - State Of New Jersey Page 2
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6Page 2
IV. INFORMATION REGARDING NONISSUER DISTRIBUTION
(Complete only if offering or any part thereof is for the benefit of selling securityholders.)
A. Name of each person on whose behalf any part of the offering is to be made: _______
_____________________________________________________________________
_____________________________________________________________________
B. Address(es): __________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
C. Amount of securities currently held by each selling securityholder: _______________
_____________________________________________________________________
_____________________________________________________________________
D. Reason (purpose) for making this offering: __________________________________
_____________________________________________________________________
_____________________________________________________________________
V. DESCRIPTION OF SECURITIES
Offering price
Total offering
Offering in this state
Description
or proposed
# of shares
$ of shares
# of shares
$ of shares
of securities
offering price
or units
or units
or units
or units
____________
___________
_________
_________
_________
_________
____________
___________
_________
_________
_________
_________
____________
___________
_________
_________
_________
_________
____________
___________
_________
_________
_________
_________
Totals
_________
_________
_________
_________
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