Form 8s - Small Issue Registration - Document And Disclosure Checklist Page 4

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Office Use ONLY Control 
#: __________  
Examiner: __________  
APPLICANT:  
Location 
Description of Document/Disclosure 
OCGA 10‐5 
14.    SELLING SHAREHOLDERS (AFFILIATES) 
5(e)(1) 
A.  Name and address 
B.  Amount of securities owned 
C.  Relationship to issuer 
15.    SPECIMEN OF SECURITIES TO BE ISSUED 
5(e)(1)(B) 
16.    STOCK/SECURITIES OPTIONS DESCRIPTION 
5(e)(3)(C) 
17.    STOCK SUBSCRIPTION AGREEMENT 
A.  Investment intent 
5(e)(1)(B) 
B.  Negotiable instruments 
19 
18.    UNDERWRITING OR SELLING GROUP AGREEMENT 
12(a)(2) 
19.  USE OF PROCEEDS 
5(e)(3)(C) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Form 8S    Rev. 9/2010 
Page 3 of 3 
 

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