NEVADA FORM 500-3
YEAR END SECURITIES SALES REPORT
TO: SECRETARY OF STATE DATE:
SECURITIES DIVISION
555 E. WASHINGTON AVE., SUITE 5200
LAS VEGAS, NV 89101
I. The undersigned hereby files a fiscal year end securities sales report pursuant to NRS 90.500
paragraph 3.
2. The following information is submitted:
Name of Issuer:
Address of Issuer:
(Street Address or Mailing Address)
(City) (State) (Zip Code)
Fiscal Year End:
Nevada Securities Division File Number:
3. I understand that this form must be accompanied by a fee of $2,000.00 or one tenth of one percent
(0. I%) of the aggregate sale price of the securities sold to persons in this state, but no less than
$350.00 or more than $2,500.00. I also understand that this year end fee is in addition to whatever
fee was filed with the initial registration statement.
a. The aggregate sale price of the securities sold under this registration to persons in Nevada
during the previous fiscal year was: $
b. The following fee is enclosed in the form of a check payable to SECRETARY OF STATE,
SECURITIES DIVISION: $
4. I understand that no acknowledgement of this filing will be made unless one additional copy
of this notice and a self-addressed, stamped envelope are submitted with the copy of this
form.
SUBMITTED BY: TEL: ( )
ADDRESS:
(Street Address or Mailing Address)
(City) (State) (Zip Code)
NOTE: In order for your report to be processed, this form must be filled out completely. Incomplete
forms will be returned.
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