Looking for a Florida Legal Forms And Templates? Download it for free!

Form Ofr-S-12-97 - Scor (Small Corporate Offering Registration) Application To Register Securites

FILE NUMBER

VAL. NUMBER

AMT.

DATE

FOR OFFICE USE ONLY

STATE OF FLORIDA

OFFICE OF FINANCIAL REGULATION

SCOR (Small Corporate Offering Registration)

APPLICATION TO REGISTER SECURITES

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

payable to: Department of Financial Services.

PART I.

GENERAL INFORMATION

Item 1.

Name and address of Issuer and principal office:

Federal Employer Identification (FEID) Number:

Item 2.

Name, address and telephone number of correspondent to whom notices and

communications regarding this application may be sent:

Item 3.

Name and address of applicant, If different from Item 1.

Item 4.

Registration is sought in this State for the following described securities in the amounts

indicated:

OFR-S-12-97, SCOR (Small Corporate Offering Registration) Effective 11/22/10, Incorporated by

Reference in Rule 69W-301.002, F.A.C.

Page 1

Form Ofr-S-12-97 - Scor (Small Corporate Offering Registration) Application To Register Securites