Form 260.105.33/34 - Notice To California Commissioner Of Corporations Of Transaction
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1Department of Corporations Use Only
DEPARTMENT OF CORPORATIONS
Fee Paid $ __________________________
FILE NO. (if any)
Receipt No. _________________________
___________________________________
Insert file number(s) of previous filings
before the Department, if any.
FILING FEE: $25.00 $35.00 $50.00 $150.00 $300.00
See instructions and Rule 260.608.3, Title 10, California Code of Regulations
NOTICE TO CALIFORNIA COMMISSIONER OF CORPORATIONS OF
TRANSACTION UNDER RULE 260.105.33 AND/OR RULE 260.105.34 UNDER THE
CORPORATE SECURITIES LAW OF 1968
( ) Original Notice
( ) Amendment to Notice dated: _______________
PLEASE COMPLETE EACH ITEM ACCORDING TO THE INSTRUCTIONS BELOW:
1.
A.
Name of Issuer: ____________________________________________________________
Insert legal name.
B.
Address of Principal Business Office of Issuer:
__________________________________________________________________________
2.
Other Issuer Information:
A.
Type of Organization: ________________________________________________________
B.
Year of Organization: ________________________________________________________
C.
State of Organization: ________________________________________________________
3.
Person to be contacted regarding this Notice:
Name: __________________________________________________________________________
Mailing Address: __________________________________________________________________
________________________________________________________________________________
Phone: ( )_______________________________________________________________________
4.
Transaction: (See Instructions on reverse)
A.
Rule Used: ( ) 260.105.33
( ) 260.105.34
B.
Proposed 1st Sale Date: _______________________________
C.
Securities Description: _________________________________
D.
Value of Securities: ____________________________________
E.
Convertible: ( ) Yes ( ) No
If Yes, Name of Class: __________________________________
5. ( ) Attached is a consent to service of process required by Corporations Code Section 25165.
6.
Execution on behalf of Issuer
Date of Notice: __________________
____________________________________________
Authorized signature on behalf of Issuer named above
___________________________________________
Printed name of signatory
___________________________________________
Title
260.105.33/34 (Register 2009, No. 46)
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