Form U-1 - Uniform Application To Register Securities - Washington State Department Of Financial Institutions

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Form U-1
Uniform Application to Register Securities
Application to_____________________________________of the State of__________________________
pursuant to Section_____________________________of the____________________________________
1. Name and address of Issuer and principal office in this state:
_______________________________________________________________________________
2. Name, address and telephone number of correspondent to whom notices and communications regarding this
application may be sent:
_______________________________________________________________________________
3. Name and address of applicant:
_______________________________________________________________________________
4. Registration or acceptance for filing is sought for the following described securities in the amounts indicated:
_______________________________________________________________________________
Total Offering
Offering in this State
Offering Price
No. of Shares
No. of Shares
Description of
or Proposed
Amount
Amount
or Units
or Units
Securities
Offering Price
$
$
Totals
$
$
Indicate the maximum commission to be charged:___________________%
5. Amount of filing and examination fees which are enclosed: $__________, $__________
6. A Registration Statement was filed with the Securities and Exchange Commission
on______________________(date) and (became) (will become) effective on____________________(date)
7. (a) List the states in which it is proposed to offer the securities for sale to the public.
(b) List the states, if any, in which the securities are eligible for sale to the public.
(c) List the states, if any, which have refused, by order or otherwise, to authorize the sale of the securities to the
public, or have revoked or suspended the right to sell the securities or in which an application has been with-
drawn.
8. Submitted herewith as a part of this application are the following documents (documents on file may be incorporated
by reference):
(a) One copy of the Registration Statement and two copies of Prospectus in the latest form on file under the
Securities Act of 1933.

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