Form SFN53493 "Affidavit of Issuer/Dealer Activity" - North Dakota

What Is Form SFN53493?

This is a legal form that was released by the North Dakota Securities Department - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the North Dakota Securities Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN53493 by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

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Download Form SFN53493 "Affidavit of Issuer/Dealer Activity" - North Dakota

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Securities Department
AFFIDAVIT OF ISSUER/DEALER ACTIVITY
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 53493 (10-2013)
(701) 328-2910
www.nd.gov/securities
Name of Applicant:
Applicant does hereby certify:
1.
That the above-named Applicant has offered for sale or sold securities, and/or solicited investors in this
state. (Attach a list of names and addresses of North Dakota residents solicited in our state.)
2. That the above-named Applicant has not offered for sale or sold any securities, and/or solicited investors in
this state.
3. That the above-named Applicant has offered for sale and sold securities, and/or solicited investors in this
state pursuant to an exempt transaction. (Please specify which exemption was relied upon):
I, on behalf of
(Name of
Applicant), acknowledge the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Securities
Department of the State of North Dakota may result in administrative action by the Department.
Signature of Officer, Partner or Sole Proprietor:
Subscribed and sworn to before me this
day of
, 20
.
Notary Public
County of
(NOTARIAL SEAL)
State of
My commission expires on
Securities Department
AFFIDAVIT OF ISSUER/DEALER ACTIVITY
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 53493 (10-2013)
(701) 328-2910
www.nd.gov/securities
Name of Applicant:
Applicant does hereby certify:
1.
That the above-named Applicant has offered for sale or sold securities, and/or solicited investors in this
state. (Attach a list of names and addresses of North Dakota residents solicited in our state.)
2. That the above-named Applicant has not offered for sale or sold any securities, and/or solicited investors in
this state.
3. That the above-named Applicant has offered for sale and sold securities, and/or solicited investors in this
state pursuant to an exempt transaction. (Please specify which exemption was relied upon):
I, on behalf of
(Name of
Applicant), acknowledge the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Securities
Department of the State of North Dakota may result in administrative action by the Department.
Signature of Officer, Partner or Sole Proprietor:
Subscribed and sworn to before me this
day of
, 20
.
Notary Public
County of
(NOTARIAL SEAL)
State of
My commission expires on