Securities Contact Form

Name

Email Address

Phone Number

Have you ever, or do you currently own your own business?
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What is the name of the business that you own, or are employed with?

What is the general nature of the business?

What is your position with the company?

What are the approximate total assets of your company?

Approximately how many shareholders?

Are your securities publicly traded?

Have you personally assisted in the filing of an SEC registration form?
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Have you personally assisted in reporting requirements under SEC regulations?
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