Form 260.507 - Application For Approval As To Form Of An Offer To Repurchase A Security

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DEPARTMENT OF CORPORATIONS
(Department of Corporations Use Only)
File No.______________________
(Insert file number of previous filings of applicant before
Fee Paid $ ____________________________
the Department, if any)
Receipt No. ____________________________
FEE: _______________________________
(To be completed by applicant)
Date of application: ___________________
DEPARTMENT OF CORPORATIONS
STATE OF CALIFORNIA
FACING PAGE
APPLICATION FOR APPROVAL AS TO FORM OF AN OFFER TO REPURCHASE A SECURITY UNDER SUBDIVISION
(b) OF SECTION 25507 OF THE CORPORATE SECURITIES LAW OF 1968.
1.
Name of issuer.
__________________________________________________________________________________________
2.
Address of principle executive office of issuer.
__________________________________________________________________________________________
Number and Street
City
State
Zip Code
3.
The name and address of each person making the offer set forth in Exhibit D of Item 9.
__________________________________________________________________________________________
Number and Street
City
State
Zip Code
4.
Name and address of persons to whom correspondence regarding this application should be addressed.
__________________________________________________________________________________________
Number and Street
City
State
Zip Code
5.
State whether issuer is a corporation, partnership, trust or other entity and the state of incorporation or jurisdiction
under which organized.
6.
(a)
(b)
(c)
(d)
Type of Security.
Number of shares or units
Aggregate value of
If a cash offer, aggregate
covered by the offer.
consideration received.
amount to be offered.
$
$
260.507 Rev. 10/02
1

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