Form 260.131 - Facing Page For Qualification Of Nonissuer Transaction By Notification - Department Of Corporations
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3(Department of Corporations use only)
DEPARTMENT OFCORPORATIONS
FILE NO.
Fee Paid $ _____________________________
________________________________
(Insert file number of previous filing of issuer
Receipt No._____________________________
before the Department, if any.)
Effective Date___________________________
Date of Application:________________
FEE: $100.00
DEPARTMENT OF CORPORATIONS
STATE OF CALIFORNIA
FACING PAGE FOR QUALIFICATION OF NONISSUER TRANSACTION BY NOTIFICATION
NOTE: Indicate the type of filing by checking the appropriate original or
amendment application heading shown below.
[ ]
APPLICATION FOR QUALIFICATION OF SECURITIES UNDER SECTION 25131 OF
THE CORPORATE SECURITIES LAW OF 1968
[ ]
AMENDMENT NUMBER_______TO APPLICATION DATED______________________
(Check and complete if applicable)
1.
Name of Issuer___________________________________________________________
2.
(a) Address of principal executive office of issuer.
_______________________________________________________________________
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
3.
Name and address of applicant if any other than the issuer.
_______________________________________________________________________
4.
Name and address of person to whom correspondence regarding this application should
be addressed.
_______________________________________________________________________
5.
State whether issuer is a corporation, partnership, trust or other entity and the State of
incorporation or jurisdiction under which organized.
_______________________________________________________________________
6.
Title and CUSIP number of each class or securities being qualified, e.g., $10 par value
common stock, CUSIP 123.
_______________________________________________________________________
(Instructions: All of the foregoing information should appear on and be the only information
appearing on the facing page of the application.)
INSTRUCTIONS
Completion of Application. The application should continue in the number sequence shown
below. Any item which is inapplicable should be listed by the number on the form, followed by the
word “inapplicable.”
7.
Describe the business done by the issuer and its subsidiaries and the general
development of such business during the last three years and indicate the intended
development of the business in the immediate future. Indicate any other names under
which the issuer or any of its subsidiaries have conducted business during such period.
8.
List the names and home addresses of all the directors and officers of the issuer,
indicating all positions and offices held by each person named. In addition, describe any
order, judgment, or decree of any governmental agency or administrator, or of any court
of competent jurisdiction, revoking or suspending for cause any license, permit or other
authority of such person or any corporation of which he is an officer or director, to engage
260.131 (Rev 9/02)
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