Uniform Notice Of Transaction Accredited Investor Exemption Form - State Of New Mexico
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3(Rev. 01/10)
UNIFORM NOTICE OF TRANSACTION
ACCREDITED INVESTOR EXEMPTION
STATE OF NEW MEXICO
NOTICE OF SALE OF SECURITIES PURSUANT TO
ACCREDITED INVESTOR EXEMPTION UNDER
RULE 12.11.12.19 NMAC
1. Issuer
Name: ___________________________________________________________________
Address: _________________________________________________________________
Phone Number: ____________________________________________________________
2. Form of Organization (Check One)
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□
□
Corporation
Unincorporated Association
Limited Liability Company
□
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Limited Partnership
Other (Specify)_____________________________________
Issuer’s state of Incorporation or jurisdiction or organization _________________________
Date of Incorporation or Organization ___________________________________________
3. Officers and Directors (or persons acting in a similar capacity)
Names, Addresses, and Phone Numbers:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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