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Form Mld-1 - Uniform Notification Form For Multi-Level Distribution Companies With A Montana Participant

Form MLD-1

UNIFORM NOTIFICATION FORM FOR MULTI-LEVEL DISTRIBUTION

COMPANIES WITH A MONTANA PARTICIPANT

(An initial notification form must be accompanied by completed schedules A & B and a consent to service of process)

This filing is:

an initial notification

an amendment

1. Company name:

2. Name under which business is conducted, if different:

3. If company or business name is being amended, give previous name:

4. Corporate address – Do not use PO box:

(City)

(State)

(Zip)

5. Mailing address (if different):

(City)

(State)

(Zip)

6. Telephone number at this location:

7. e-mail address:

8. Web site URL:

(

)

9. State of domicile:

10. State of Incorporation:

11. Date of Incorp.

Execution

Both the undersigned and the above named multi-level distribution company

represent that the information and statements contained herein, including attached

schedules, exhibits and other information field herewith, are current, true, and

complete. Both parties further represent that, to the extent that any information

previously submitted is not amended, such information is currently accurate and

complete.

Date:

Name of multi-level distribution company:

By: (Signature)

Type name and title:

Note: The company is required by law to file an amendment with the State

Auditor’s Office each time there is a material change to the information contained

within this form.

Orig. 9/99

Form Mld-1 - Uniform Notification Form For Multi-Level Distribution Companies With A Montana Participant