Issuer Profile Official Name of Corporation Tax Payer I.D.
Date of Incorporation SIC Code
State of Incorporation
Date of Annual Meeting
Exchange Listing
Principal Contact Name: Title: Address: City:
State:
ZIP Code:
Phone:
Cell:
Email:
State:
ZIP Code:
Billing Contact Name: Title: Address: City: Phone:
Email:
SEC Counsel Name: Firm: Address: City:
State:
Phone:
ZIP Code: Email:
General Counsel Name: Firm: Address: City:
State:
Phone:
ZIP Code: Email:
Auditor Name: Firm: Address: City:
State:
Phone:
ZIP Code: Email:
CAPITAL STOCK Class of Stock (Include un-exchanged Issues)
ClearTrust is the Agent (Yes or No)
CUSIP Number
Par Value
Authorized Shares
Ticker Symbol
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Customized Service Reporting & Shell Status: Please check all that apply ☐ The Company is considered fully Reporting ☐ The Company is considered Non-Reporting
☐ The company has never been considered a shell
☐ The company was considered a shell between the dates of _______________ and _______________
☐ The company is currently a shell, and became a shell on _______________
Privacy: Please instruct us on how to respond to all normal inquiries regarding share structure coming from brokers, shareholders, attorney’s acting on behalf of shareholders, and auditors not listed on the third party authorization portion. Please select one of the options ☐ ClearTrust is to notify all inquirers to rely on current public filings for share structure information.
☐ ClearTrust is to obtain authorization from the issuer prior to giving out share structure information.
☐ ClearTrust is authorized to give out share structure information as requested by inquirers.
Legal Opinions: Please select your preferences for legal opinions written for legend removals and other transfers. ☐ Only opinions from retained corporate counsel are acceptable.*
☐ Opinions from any qualified securities counsel are acceptable.
*ClearTrust will send you a copy of any opinion written by outside counsel for your review.
Specimen Signatures for Certificates:
Title: President
Title: Secretary
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List of Officers, Directors, Control Persons, and Authorized Personnel SEC Rule 144 Affiliates* (Yes or No) Name
Authorized to provide instructions (Yes or No)
Authorized to receive reports (Yes or No)
MUST BE COMPLETED
Title
Yes
Yes
Yes
* As defined in SEC Rule 144
Date
Signature
Name & Title
Please Note: This form constitutes your Profile. If any of the information contained herein becomes inaccurate or out of date, please contact us immediately to update your Profile:
[email protected]. This form can be completed or downloaded at www.cleartrusttransfer.com. Click on Library of Forms then List of Authorized Personnel. Page 3 of 3
