Form 3401 - Telephone Solicitation Registration Statement Page 6
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7Executed the
____________
day of
_
_____________________
____ __________
,
at
______________________ _______________________ _____________.
,
,
(Give City, County & State)
BY:
________________________________
BY:
_
________________________________
(Signature of Principal)
(Signature of Principal)
____________________________________
____________________________________
(Printed Name & Title)
(Printed Name & Title)
BY:
________________________________
BY:
_________________________________
(Signature of Principal)
(Signature of Principal)
____________________________________
____________________________________
(Printed Name & Title)
(Printed Name & Title)
State of
__________________________
County of
________________________
Before me, a notary public, on this day personally appeared
_____________________________________
known to me to be the persons whose names are subscribed to the foregoing document and, being duly sworn,
declared that the statements therein contained are true and correct.
Given under my hand and seal of office this
_________
day of
________________________ ________
,
.
____________________________________
____________________________________
(Notary Signature)
(Printed Name)
(seal)
My commission expires
________________________
Print
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<<<<<<<<<<<>>>>>>>>>>>
(The above verification statement must be completed and signed by each principal of the seller.
Additional verifications may be added for additional signers if needed.) "Principal" means an owner, an
executive officer of a corporation, a general partner of a partnership, a sole proprietor, a trustee of a
trust, or another individual with similar supervisory functions with respect to any person. "Owner"
means a person who owns, controls, or otherwise has claim to 10 percent or more of the net income of a
seller.
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