N.J. Admin. Code § Tit. 13, ch. 47A, subch. 10, app B

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Current through Register Vol. 56, No. 21, November 4, 2024

Appendix B

NEW JERSEY REGISTRATION STATEMENT FOR REGISTRATION BY NOTIFICATION

All items must be answered. Attach riders where necessary.

I. DESCRIPTION OF ISSUER

A. Name:

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B. Address:

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C. Form of organization:

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State:

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Date organized:

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D. General character of business:

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E. Principal place of business:

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II. DESCRIPTION OF SUBSIDIARIES

(State the information requested in Question 1 for each significant subsidiary of the issuer.)

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III. DESCRIPTION OF APPLICANT

(Complete if applicant is not the issuer.)

A. Name:

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B. Address:

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C. Relationship to issuer:

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IV. INFORMATION REGARDING NONISSUER DISTRIBUTION

(Complete only if offering or any part thereof is for the benefit of selling securityholders.)

A. Name of each person on whose behalf any part of the offering is to be made :

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B. Address(es):

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C. Amount of securities currently held by each selling securityholder:

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D. Reason (purpose) for making this offering:

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V. DESCRIPTION OF SECURITIES

Description	Offering price	Total offering	Offering in
of securities	or proposed	No. of shares	this state
offering price	or units	No. of shares
Amount	or units	Amount
$	$
Totals	$	$

VI. INFORMATION AND DOCUMENTS REQUIRED

(See N.J.S.A. 49:3-61.3(b)(10), 61.3(b)(12), and 61.3(b)(14)).

A. States in which a registration statement or similar document in connection with this offering has been or is to be filed.

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B. State whether any withdrawal or any adverse order, judgment, or decree has been entered in connection with this offering by the regulatory authorities in any state or by any court or by the Securities and Exchange Commission.

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If so, give details.

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(1) Proposed offering price per unit (or the method by which it is to be computed).

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(2) State whether the price will vary as to any person or class of persons other than underwriters.

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If so, give details.

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(3) Is this offering, or any part thereof, to be made other than for cash?

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If so, give details.

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(1) Estimated aggregate underwriting and selling discounts or commissions and finders fee. Show each means of payment separately (e.g., cash, securities, contracts).

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(2) If the selling discounts and commissions are variable, state the basis of determining them, including their maximum and minimum amount.

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(3) State the estimated amounts of other selling expenses, including legal, engineering and accounting expenses.

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(1) The name and address of every underwriter, agent, broker-dealer or other recipient of a commission, discount or finders fee. (Submit the underwriting agreement or form of underwriting agreement as an exhibit.)

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(2) If the securities are not to be offered through an underwriter, describe the plan of distribution.

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(3) Identify the agent or broker-dealer registered in New Jersey who will offer the securities or state the applicable exemption.

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F. Description of any stock options outstanding or to be created in connection with this offering.

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G. List Dollar amount of options held by each of the following:

Name and address	Dollar amount
of options held
1. Each director or officer of the issuer or person occupying
a similar status.
2. Any person owning of record, or beneficially if known, at
least 10% of the outstanding shares of any class of equity
security of the issuer.
3. Every promoter of the issuer if the issuer was organized
within the past 3 years.
4. If this is a nonissuer distribution, any person on whose
behalf this offering is to be made.
5. Every underwriter or recipient of a finders fee (every
person listed in paragraph E).
6. Every person who holds or will hold 10% or more in the
aggregate of such options.

H. EXHIBITS

Submitted herewith as part of this registration statement are the following documents. (Documents on file may be incorporated by reference.)

1. A statement of eligibility for registration by notification.

2. A copy of the underwriting or selective dealer agreement (or the proposed form).

3. A copy of any prospectus, pamphlet, circular, form letter, advertisement, or other sales literature intended to be used in connection with this offering.

4. A consent to service of process of the issuer (with appropriate resolution).

5. The New Jersey Addendum.

6. Financial statements pursuant to 49:3-61.2(b)(6), specifically:

(a) A balance sheet of issuer as of a date within 4 months prior to the filing of this registration statement; and

(b) A summary of earnings for each of the 2 fiscal years preceding the date of the balance sheet, and summary of earnings for any period between the close of the last fiscal year and the date of the balance sheet, or for the period of the issuer's and any predecessor's existence if less than 2 years.

7. The registration fee of $ 5,000.00.

________________

Name of Applicant

By:

_________________________.

(Name and Title)

Date: ._____________________________

STATE OF________________________

COUNTY OF______________________

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________, 20___

_________________________________

NOTARY PUBLIC

In and for the County of__________

State of_________________________

My Commission Expires:

(Notarial Seal)__________________

N.J. Admin. Code Tit. 13, ch. 47A, subch. 10, app B

Amended by 51 N.J.R. 1467(a), effective 9/16/2019

Amended by 56 N.J.R. 1986(a), effective 10/7/2024