Form Ofr-S-1-91 - Application For Registration Of Securities - Florida Office Of Financial Regulation
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5STATE OF FLORIDA
OFFICE OF FINANCIAL REGULATION
APPLICATION FOR REGISTRATION OF SECURITIES
SECTION 517.081, FLORIDA STATUTES
(Application may be made by the issuer or by a registered dealer)
NOTE:
The general information required under Part I of this application form must be supplied, when
applicable, by every applicant and concerning every issue sought to be registered.
A fee of $1,000 shall accompany every application for registration.
Checks should be made payable to: Department of Financial Services
PART I. GENERAL INFORMATION
1. Name and address of issuer and principal office
Florida File No. _______________
(For Office Use Only)
Name
Federal Employer Identification No.
Street Address, Suite No.
(FEID)
City
State
Zip+4
2. Name, address and telephone number of
3. Name and address of Applicant:
correspondent to whom notice and communications
regarding this notification may be sent.
Correspondent Name
Applicant Name
Street Address, Suite No.
Phone No.
Street Address, Suite No.
Phone No.
City
State
Zip+4
City
State
Zip+4
4. Registration is sought in this State for the following described securities in the amounts indicated:
DESCRIPTION OF SECURITIES
Title of class of securities to be registered: ____________________________________________________
Offering Price
TOTAL OFFERING
Or Proposed Offering Price: _______________
No. of Shares or Units: _______________
Total $ Amount:
_______________
5. Officials of Issuer:
Give the names, titles and residence address of officers, director, trustees and executive manager or other
officials, of the issuer as of the date of filing this application.
Name
Position/Title
Residence Address
Phone No.
OFR-S-1-91, Application for Registration of Securities, Effective 11/22/10, Incorporated by Reference in Rule 69W-
301.0002, F.A.C.
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