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Directors & Officers (D&O) Application

Company Name
Street Address, Include Floor #
City
State
Zip
Tel #
Contact Name
Contact Title
Contact Tel#
Contact e-mail
Website (if any)
Brief Description of operations
Date of Incorporation
# common shares outstanding
Total # of common shareholders
Total # of common shares held directly of beneficially by Directors and Officers
Names and % owned for shareholders who directly or beneficially own 5% or more
Any changes in Executive Officers or Directors in past 12 months?
Any planned merger or acquisition in the next 12 months?
Any current litigation against the company?
Total Assets?
Total Liabilities?
Annual Revenues?
Annual Net Income?

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