Form 203-O - Application Under Section 203(O) Of The Pennsylvania Securities Act Of 1972 - 2013
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3FORM 203-O
PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES
CORPORATION FINANCE OFFICE
APPLICATION UNDER SECTION 203(O) OF THE
PENNSYLVANIA SECURITIES ACT OF 1972
____________________________________________________________________________________
_
1.
Exact Name of Issuer:____________________________________________________________
2.
(A) Address of Principal Office of
Issuer:_____________________________________________
Number and Street
______________________________________________________________________________
City
State
Zip Code
Telephone No.
(B) Address of Principal Office of Issuer in Pennsylvania (if other than listed in (A)):
______________________________________________________________________________
Number and Street
City
State
Zip Code
Telephone No.
3.
(A) Name and address of person to whom correspondence regarding this filing should be sent:
______________________________________________________________________________
Name
Title
Number and Street
______________________________________________________________________________
City
State
Zip Code
Telephone No.
(B) Name and address of counsel to Issuer (if other than listed in (A)):
______________________________________________________________________________
Name
Number and Street
______________________________________________________________________________
City
State
Zip Code
Telephone No.
(C) Name and address of accountants of Issuer:
______________________________________________________________________________
Name
Number and Street
______________________________________________________________________________
City
State
Zip Code
Telephone No.
FORM 203-O
3
REVISED: 7/31/2013
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