Psc Form R - Application To Register Securities Under The Pennsylvania Securities Act Of 1972 Page 2
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53.
Information about the Executive Officers of the Issuer
(A)
State the names and addresses of persons holding any of the following positions with
the Issuer:
(i)
General partner
(ii)
Promoter (as defined in Section 102(o) of the Act)
(iii)
M anager (if a limited liability company)
(iv)
President
(v)
Chief executive officer
(vi)
Chief operating officer
(vii)
Chief financial officer
(viii)
Director of the Issuer who owns 5% or m ore of any class of voting equity
securities of the Issuer (exclusive of any beneficial interest in a voting
shareholder which is an institutional investor as defined in Section 102(k) of
the Act and Regulation 102.111).
(B)
Indicate if any person described in (A) currently is registered as an agent under Section
301 of the Act or as a principal of a broker-dealer registered under Section 301 of the
Act.
NO
YES
If YES, provide the individual’s name, em ployer and Central Registration Depository
number.
4.
Prior Disciplinary History
(A)
Indicate if any person described in Item 3(A) has been convicted of any crime or made
the subject of any sanction described in Section 305(a)(ii)-(ix) of the Act.
NO
YES
If YES, describe fully.
(B)
Indicate if any person described in Item 3(A) has been the subject of a Commission
order issued under Section 512 (Statutory Bars) or Section 513 (Rescission Offer) of the
Act or an order of a court of competent jurisdiction under Section 509(c) of the Act
(Civil Contempt).
NO
YES
If YES, describe fully.
5.
Previous Sales of Securities in Pennsylvania
(A)
By the Issuer
Describe all sales of securities made in Pennsylvania during the past two years that directly or
indirectly benefitted the Issuer. Include securities issued in exchange for property, services, or
other securities and new securities resulting from the modification of outstanding securities. In
each case, state:
(i)
The date of sale and description of the securities sold;
(ii)
Underwriting or selling fees or commissions paid and to whom paid;
(iii)
Section of the Act or regulation relied upon for the offer and sale of securities.
NO
YES
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