Form E (SFN51717) "Limited Offeree Exemption Application" - North Dakota

What Is Form E (SFN51717)?

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 August 1, 2021;
  • 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 E (SFN51717) by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

ADVERTISEMENT
ADVERTISEMENT

Download Form E (SFN51717) "Limited Offeree Exemption Application" - North Dakota

Download PDF

Fill PDF online

Rate (4.8 / 5) 23 votes
Page background image
FORM E
LIMITED OFFEREE EXEMPTION APPLICATION
Securities Department
NORTH DAKOTA SECURITIES DEPARTMENT
600 E Boulevard Ave Dept 414
Bismarck ND 58505
SFN 51717 (08-2021)
(701) 328-2910
www.securities.nd.gov
1. Name of Applicant
Telephone Number
Address of Applicant
City
State
ZIP Code
Relationship of Applicant to Issuer
2.
Telephone Number
Name of Issuer
Address of Issuer
City
State
ZIP Code
Issuer's state of incorporation or jurisdiction of organization and date of incorporation or organization
Date:
State:
Names of all promoters, incorporators, directors, and officers of the issuer, indicating all
positions and offices with the issuer presently held by each such person.
General character of issuer's business:
List the states in which it is proposed to offer the securities for sale
3
.
List the states, if any, in which the securities are eligible for sale
List the states, if any, which have refused, by order or otherwise, to authorize the sale of securities or
have suspended or revoked the right to sell the securities, or in which an application has been withdrawn:
FORM E
LIMITED OFFEREE EXEMPTION APPLICATION
Securities Department
NORTH DAKOTA SECURITIES DEPARTMENT
600 E Boulevard Ave Dept 414
Bismarck ND 58505
SFN 51717 (08-2021)
(701) 328-2910
www.securities.nd.gov
1. Name of Applicant
Telephone Number
Address of Applicant
City
State
ZIP Code
Relationship of Applicant to Issuer
2.
Telephone Number
Name of Issuer
Address of Issuer
City
State
ZIP Code
Issuer's state of incorporation or jurisdiction of organization and date of incorporation or organization
Date:
State:
Names of all promoters, incorporators, directors, and officers of the issuer, indicating all
positions and offices with the issuer presently held by each such person.
General character of issuer's business:
List the states in which it is proposed to offer the securities for sale
3
.
List the states, if any, in which the securities are eligible for sale
List the states, if any, which have refused, by order or otherwise, to authorize the sale of securities or
have suspended or revoked the right to sell the securities, or in which an application has been withdrawn:
SFN 51717 (8-2021)
Page 2 of 4
4. Title or class of each security to be offered for sale
Total dollar amount of securities to be sold in all jurisdictions
Price per share or other unit of each security to be offered for sale
Have any securities of the kind to be offered pursuant to this application for exemption been offered for
sale or sold during the preceding twelve months for a consideration other than or different from that at
Yes
No If yes, please explain the difference.
which they are now proposed to be offered for sale.
Minimum dollar amount of securities which will be offered to any one offeree
$
5
Number of offerees to whom securities will be offered in North Dakota: (The number of offerees must
.
be stated numerically.)
Name and state briefly the relationship of each of the proposed offerees to the issuer and offeror and
any of their directors, officers, promoters, or incorporators. If the identities of any of the offerees have
not been determined as of the date of the application, indicate the standards which have been
established for selecting the offerees in terms of their relationship to or familiarity with the issuer and
its financial and business matters:
What precautions, if any, will be taken to assure that the securities being offered for sale are suitable
investment vehicles for the offerees?
Number of offerees to whom securities were offered in North Dakota during the twelve consecutive
months preceding the date of this application, other than offerees designated in N.D.C.C. Section
10-04-06(5):
Number of North Dakota offerees designated in N.D.C.C. Section 10-04-06 (5) to whom securities
were offered during the twelve consecutive months preceding the date of this application:
6
.
Furnish the names of any entities and persons who will act on behalf of the issuer or offerer in
effecting the offers and sales of securities in North Dakota.
State the compensation to be paid directly or indirectly to the entities or persons identified in above (box).
SFN 51717 (8-2021)
Page 3 of 4
7
.
Estimated cash proceeds to be received by the issuer from the offering:
Specify the purposes for which the proceeds are to be used and the amount to be used for each
purpose specified:
Amount and other sources of funds to be raised in conjunction with the offering to achieve the
purposes stated:
8
Provide an estimated itemization of all costs and expenses to be incurred in connection with the offering:
.
Include the following as exhibits:
9
.
(1) Articles of incorporation and by-laws or
(4) A copy of the offering disclosure document
similar documents, as currently effective
(5) Other disclosures as required by Commissioner
(2) A specimen of the security, if available
(3) A copy of any indenture (bond, trust)
10.
A $150 filing fee must be paid electronically through the filing portal at time of the application submission.
11.
If there is any information not elicited by the foregoing questions which you feel is material and might
influence the Commissioner to determine whether to approve the requested exemption, state that
information here:
SFN 51717 (8-2021)
Page 4 of 4
Signature and Submission
By submitting this application, the undersigned affirms that this application has been filed on behalf
of, and with the authority of the issuer. The undersigned and the issuer represent that the
information submitted is current, true, and complete.
The undersigned, on behalf of the issuer, irrevocably appoints the North Dakota Securities
Commissioner as the issuer’s agent for service of process, and agrees that the Securities
Commissioner may accept service on its behalf, of any notice, process or pleading in any action or
proceeding against it arising out of, or in connection with, the sale of securities or out of violation of
the securities laws and rules of the state of North Dakota, and further agrees that such service
may be made by registered or certified mail. The undersigned, on behalf of the issuer, does
hereby consent that any such action or proceeding against it may be commenced in any court of
competent jurisdiction and proper venue within the State of North Dakota. It is requested that a
copy of any notice, process, or pleading served hereunder be mailed to:
Name
Address
The issuer has read this notice, knows the contents to be true, and has duly caused this notice to be
signed on its behalf by the undersigned duly authorized person.
Typed or Printed Name of Signatory
Title
Date
Signature
Page of 4