Form 9 - Application To Register By Qualification Securities Pursuant To Section 1707.09 Of The Revised Code Of Ohio - Ohio Dept. Of Commerce

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nd
77 South High Street, 22
Floor
File Number
Columbus, Ohio 43215-6131
Telephone: (614) 644-7381
Form 9
Application to Register by Qualification Securities
Pursuant to Section 1707.09 of the Revised Code of Ohio
Registrant Must Not fill In.
Checked
Division Record --
Date
By
Notation
Fee ($100 Received)
Examination expenses ($
) received
Qualification fee ($
) received
Prior registrations checked
Examined as to form
Assigned for examination
Division Order (Application Refused or
Granted)
Record Made
Registration withdrawn
Registration amended
Registration suspended
Examination requested
Prior Registration (Registrant Must Not Fill In.)
(Section) (File)
(Date)
(Amount)
(Description)
(Price)
This Registration (Registrant Must Not Fill In.)
(Section)
(File)
(Date)
(Amount)
(Description)
(Price)
1.
Name of
issuer
Payer’s Federal Tax Identification Number
2.
Principal place of business of
issuer
Number, Street
(City, State, Zip)
3.
The issuer is: (State whether individual, partnership corporation, syndicate, association,
etc.)

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