Psc Form R - Application To Register Securities Under The Pennsylvania Securities Act Of 1972

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PSC FORM R
EFFECTIVE: 9/2/00
SUPPLEMENT TO FORM U-1
REVISED: 12/23/04
COM M ONW EALTH OF PENNSYLVANIA
PENNSYLVANIA SECURITIES COMM ISSION
APPLICATION TO REGISTER SECURITIES UNDER
THE PENNSYLVANIA SECURITIES ACT OF 1972
(CHECK ONLY ONE)
SECTION 205 - REGISTRATION BY COORDINATION [ ]
SECTION 206 - REGISTRATION BY QUALIFICATION [ ]
1.
Legal Status of the Issuer
(A) Exact name of Issuer:
(B) State and Date of incorporation or form ation:
State
Date
2.
Addresses
(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.
(C) 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.
(D) Name and address of counsel to Issuer (if other than listed in (C)):
Name
Title
Number and Street
City
State
Zip Code
Telephone No
26

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