Form Njbos-6 - Registration Statement For Registration By Notification - State Of New Jersey Page 6

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Page 6
the date of the balance sheet, or for the period of the issuer’s and any predecessor’s exis-
tence if less than 2 years.
7. The registration fee of $1,000.00.
________________________________
Name of Applicant
By: _____________________________
(Name and Title)
DATE: ____________________________
STATE OF _________________________
COUNTY OF _______________________
The undersigned, ____________________________, being first duly sworn, deposes and says:
That he has executed the foregoing application for and on behalf of the applicant named therein;
that he is ______________________________ of such applicant and is fully authorized to exe-
cute and file such application; that he is familiar with such application; and that to the best of his
knowledge, information and belief the statements made in such application are true and the docu-
ments submitted therewith are true copies of the originals thereof.
__________________________________
Name
Subscribed and sworn to before me
this _____ day of ______________, 20___
___________________________________
___________________________________
NOTARY PUBLIC
In and for the County of _______________
State of ____________________________
My Commission Expires: ______________
(Notarial Seal)
Form NJBOS-6
9/2003

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