Illinois Administrative Code › Title 14 - COMMERCE › Part 130 - REGULATIONS UNDER ILLINOIS SECURITIES LAW OF 1953 › Subpart Q - PUBLIC INFORMATION › Appendix B - Uniform Application to Register Securities

Current through Register Vol. 48, No. 28, July 12, 2024
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:
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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
_______ and (became) (will become) ______
(date)
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 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				  application has been withdrawn.
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.
(b) Underwriting Agreement, Agreement among
				  Underwriters, and Selected Dealers Agreement.
(c) Indenture.
(d) Issuer's charter or articles of incorporation
				  as amended to date.
(e) Issuer's by-laws as amended to date.
(f) Signed copy of opinion of counsel filed with
				  Registration Statement pursuant to the Securities Act of 1933.
(g) Specimen (type of security)
(h) Consent to service of process accompanied by
				  appropriate corporate resolution.
(i) If an earning computation or similar
				  requirement is required to be met in this state, attach a separate sheet as an
				  exhibit showing compliance.
(j) One copy of all advertising matter to be used
				  in connection with the offering.
(k) Others (list each):
9. The applicant hereby applies for registration
				  or acceptance for filing of the above described securities under the law cited
				  above and in consideration thereof agrees so long as the registration remains
				  in effect that it will:
(a) Advise the above named state authority of any
				  change prior to registration in this state in any of the information contained
				  herein or in any of the documents submitted with or as a part of this
				  application.
(b) File with the above named state authority
				  within two business days after filing with the Securities and Exchange
				  Commission (i) any amendments other than delaying amendments to the federal
				  registration statement, designating the changed, revised or added material or
				  information by underlining the same; and (ii) the final prospectus, or any
				  further amendments or supplements thereto.
(c) Notify the above named state authority within
				  two business days (i) upon the receipt of any stop order, denial, order to show
				  cause, suspension or revocation order, injunction or restraining order, or
				  similar order entered or issued by any state or other regulatory authority or
				  by any court, concerning the securities covered by this application or other
				  securities of the issuer currently being offered to the public; and (ii) upon
				  the receipt of any notice of effectiveness of said registration by the
				  Securities and Exchange Commission.
(d) Notify the above named state authority at
				  least two business days prior to the effectiveness of said registration with
				  the Securities and Exchange Commission of (i) any request by the issuer or
				  applicant to any other state or regulatory authority for permission to withdraw
				  any application to register the securities described herein; and (ii) a list of
				  all states in which applications have been filed where the issuer or applicant
				  has received notice from the state authority that the application does not
				  comply with state requirements and cannot or does not intend to comply with
				  such requirements.
(e) Furnish promptly all such additional
				  information and documents in respect to the issuer or the securities covered by
				  this application as may be requested by the above named state authority prior
				  to registration or acceptance for filing.
Date _________________
_______________
Name of Applicant
By ____________
(Name and Title)
STATE OF
COUNTY OF
)
)
ss.
The undersigned, _____________ being first duly
				  sworn, deposes and says: That he has executed the foregoing application for and
				  on behalf of the applicant named therein; that he is_____________
				  of such applicant and is fully authorized to execute and file such application;
				  that he is familiar with such application; and that to the best of his
				  knowledge, information and belief the statements made in such application are
				  true and the documents submitted therewith are true copies of the originals
				  thereof.
____________________
Name
Subscribed and sworn to before me this _____day of
_______________, 19 ____
NOTARY PUBLIC
In and for the County of _____________
State of ______________
My Commission Expires: ____________
(Notarial Seal)