Form Fis 0564 - Application To Register Securities By Notification

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FIS 0564 (5/04) Office of Financial and Insurance Services
APPLICATION TO REGISTER SECURITIES BY NOTIFICATION
1. Issuer Information
Name
Address (number, street, city, state, zip code)
State
Organization: Form
Date Organized
General character of business
Location of business
2. For each significant subsidiary of the Issuer state
Name
Address (number, street, city, state, zip code)
Organization: Form
State
Date Organized
General character of business
Location of business
3. Applicant Information
Name (Issuer / Offeror / Registered Broker-Dealer)
Address (number, street, city, state, zip code)
4. If any part of the offering is a non-issuer distribution, state the following information as to each person on whose
behalf this offering is made:
Name
Address (number, street, city, state, zip code)
Amount of Issuer's securities held by at this date:
Amount of above owner's securities being offered:
Reason for making this offering:
(Submit the above information by separate exhibit if more than one person is involved)
ALL QUESTIONS MUST BE ANSWERED. RIDERS MAY BE ATTACHED.
This form is issued under Act 265, PA 1964, as amended. You must complete and submit this form if you wish to make an application for registration under Section 302 of the
Act.

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