Form 260.110 - Application For Qualification Of The Offer And Sale Of Securities
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1
2(Department of Corporations Use Only)
DEPARTMENT OF CORPORATIONS
Fee Paid $ __________________________
FILE NO.
(Insert file number of previous filings of
Applicant before the Department, if any)
Receipt No. _________________________
Effective Date ______________________
FEE:_________________________________
__________________________________
(To be completed by Applicant)
Date of Application:_________________
DEPARTMENT OF CORPORATIONS
STATE OF CALIFORNIA
FACING PAGE
Application for qualification of the offer and sale of securities under the
Corporate Securities Law of 1968, by (check one):
( ) Coordination, Section 25111
( ) Post-Effective
) Amendment
( ) Notification, Section 25112
) Number ______________
( ) Permit,
Section 25113(b)(1)
) To Application
( ) Permit (Small Company),
Section 25113(b)(2)
) Filed Under
( ) Permit,
Section 25121
) Section ______________
( ) Negotiating Permit,
Section 25102(c)
( ) Pre-Effective
) Dated ________________
This application is for an ( ) open or ( ) limited offering qualification as defined in Section 260.001
of the rules (Check as applicable).
1. Name of Applicant
________________________________________________________________________________
2. (a) Is applicant a corporation, partnership, trust or other entity? __________________________
(b) State of incorporation or jurisdiction under which organized?_________________________
(c) If a corporation, is applicant in good standing in the State of its incorporation?
(Indicate “yes” or “no”)_______________________________________________________
(d) Is applicant a registered investment company? (Indicate “yes” or “no”)_________________
3. (a) Address of principal executive office of applicant.
Number and Street
City
State
ZIP Code
________________________________________________________________________________
(b) Is the principal location of applicant's books and records at the address of the principal
executive office, above? (Indicate “yes” or “no”). If “no”, provide address:
Number and Street
City
State
ZIP Code
________________________________________________________________________________
4. Name and address of person to whom correspondence regarding this application should be
addressed.
260.110 (Rev 7/93, Register 1993, No. 27)
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