NEW JERSEY INTERNET SITE OPERATOR (ISO) AMENDMENT FORM

NJBOS Form 10
NEW JERSEY INTERNET SITE OPERATOR (ISO) REGISTRATION FORM (FORM ISO)

Pursuant to N.J.S.A. 49:3-80
This form is for use in filing for registration as a New Jersey Internet site operator (“ISO”), as defined by N.J.S.A. 49:3-49(x), pursuant to N.J.S.A. 49:3-80. This form may also be used for successor registration to a Bureau registered ISO. Broker-Dealers registered with the Bureau providing ISO services do not need to separately register as an ISO.

If this is an initial application for registration, mail proof of submission of this form which you will receive via e-mail, together with a $1,800 filing fee made payable to the New Jersey Bureau of Securities to: 153 Halsey Street, 6th Floor, Newark, New Jersey, 07102. A fee is not assessed for successor registrants.

The application will not be deemed complete, and the review period will not begin, until all applicable requirements are met. An ISO's registration must become effective before posting any offerings on the ISO’s website.

An ISO must file with the Bureau an amendment on a Form ISO-A when any information previously submitted on the Form ISO or Form ISO-A changes for any reason. The ISO must file the Form ISO-A with the Bureau within 30 days of any change to the information or responses to any previously filed Form ISO or ISO-A.
Submission Type:*

Initial ApplicationSuccessor Registration
APPLICANT INFORMATION
Full Name:*
IRS Employer Identification Number:*
Additional name(s) under which business is conducted (if applicable):
Primary business address (do not use a P.O. Box):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone Number:*

Area CodePhone Number
Website(s) URL:*
Contact Employee:*

First NameLast Name
Contact Employee Title:*
Contact Employee E-mail:*
Contact Employee Phone Number:*

Area CodePhone Number
Contact Employee Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
FORM OF ORGANIZATION
Pursuant to N.J.S.A. 49:3-80(4)(a)(1), the Internet site operator must be a business entity organized under the laws of New Jersey and authorized to do business in New Jersey.
Legal form of Registrant/Successor:*

CorporationPartnershipLimited Liability CompanyOther
Specify:
Date of Formation:*

MonthDayYear
Upload copies of formation documents:*

Upload a File

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BUSINESS OPERATIONS
Has the ISO ever operated in the State of New Jersey?*

YesNo
If Yes, please explain:*
Is the ISO offering or selling securities other than pursuant to N.J.S.A. 49:3-50(b)(14)?*

YesNo
If Yes, please explain:*
Is the ISO an SEC Registered Funding Portal?*

YesNo
Upload the SEC Form Funding Portal – Application or Amendment to Application for Registration or Withdrawal from Registration as a Funding Portal Under the Securities Exchange Act of 1934 *

Upload a File

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Upload a fully executed Form U2 - Consent to Service of Process*

Upload a File

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SUCCESSOR INFORMATION
Is the Registrant at the time of this filing a successor to a company?*

YesNo
If Yes, name of the predecessor company:*
If Yes, nature of the predecessor company business:*
If Yes, is the predecessor company a New Jersey registered ISO?*

YesNo
If Yes, New Jersey ISO number:*
NON-SECURITIES RELATED BUSINESS
Does the Applicant engage in any non-securities related business?*

YesNo
If Yes, briefly describe the non-securities business:*
MANAGEMENT AND OWNERSHIP INFORMATION

Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO:*

	Full Name	DE/FE/I	Title	IRS Tax No. or Employer ID No.	Residential Address
1
2
3
4
5
6
7
8
9
10

If you need more than 10 rows, upload a document with the required information.

Upload a File

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DISCLOSURE INFORMATION
Provide disciplinary history information about the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO. One event may result in the requirement to answer “yes” to more than one of the questions below.
Criminal Actions: Check all that apply.
Has the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO been convicted, within ten years, of any felony or misdemeanor:
In connection with the purchase or sale of any security?*

YesNo
Involving the making of any false filing with the Securities and Exchange Commission?*

YesNo
Arising out of the conduct of the business of an underwriter, broker, dealer, municipal securities dealer, investment adviser, or paid solicitor of purchasers of securities?*

YesNo
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO, subject to a United States Postal Service false representation order entered within five years or subject to a temporary restraining order or preliminary injunction with respect to conduct alleged by the United States Postal Service to constitute a scheme or device for obtaining money or property through the mail by means of false representations?
YesNo
State Regulatory Actions: Check all that apply.
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO subject to a final order of a state securities commission (or an agency or office of a state performing like functions); a state authority that supervises or examines banks, savings associations, or credit unions; a state insurance commission (or an agency or office of a state performing like functions); an appropriate federal banking agency; the U.S. Commodity Futures Trading Commission; or the National Credit Union Administration that:
Bars the person from association with an entity regulated by such commission, authority, agency, or office?*

YesNo
Bars the person from engaging in the business of securities, insurance, or banking?*

YesNo
Bars the person from engaging in savings association or credit union activities?*

YesNo
Constitutes a final order based on a violation of any law or regulation that prohibits fraudulent, manipulative, or deceptive conduct entered within the past ten years?*

YesNo
Federal Regulatory Actions. Check all that apply.
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO subject to an order of the Securities and Exchange Commission entered pursuant to section 15(b) or 15B(c) of the Securities Exchange Act of 1934 (15 U.S.C. 78o(b) or 78o-4(c)) or section 203(e) or (f) of the Investment Advisers Act of 1940 (15 U.S.C. 80b-3(e) or (f)) that:
Suspends or revokes such person’s registration as a broker, dealer, municipal securities dealer, or investment adviser?*

YesNo
Places limitations on the activities, functions, or operations of such person?*

YesNo
Bars such person from being associated with any entity or from participating in the offering of any penny stock?*

YesNo
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO subject to any order of the Securities and Exchange Commission entered within five years that orders the person to cease and desist from committing or causing a violation or future violation of:
Any scienter-based anti-fraud provision of the federal securities laws, including without limitation section 17(a)(1) of the Securities Act of 1933 (15 U.S.C. 77q(a)(1)), section 10(b) of the Securities Exchange Act of 1934 (15 U.S.C. 78j(b)) and 17 CFR 240.10b–5, section 15(c)(1) of the Securities Exchange Act of 1934 (15 U.S.C. 78o(c)(1)) and section 206(1) of the Investment Advisers Act of 1940 (15 U.S.C. 80b–6(1)), or any other rule or regulation thereunder?*

YesNo
Section 5 of the Securities Act of 1933 (15 U.S.C. 77e)?*

YesNo
Civil Judicial Actions. Check all that apply.
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO subject to any order, judgment or decree of any court of competent jurisdiction, entered within the past five years, that restrains or enjoins such person from engaging or continuing to engage in any conduct or practice:
In connection with the purchase or sale of any security?*

YesNo
Involving the making of any false filing?*

YesNo
Arising out of the conduct of the business of an underwriter, broker, dealer, municipal securities dealer, investment adviser, or paid solicitor of purchasers of securities?*

YesNo
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO suspended or expelled from membership in, or suspended or barred from association with a member of, a registered national securities exchange or a registered national or affiliated securities association for any act or omission to act constituting conduct inconsistent with just and equitable principles of trade?
YesNo
Has the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO filed (as a registrant or issuer), or was or was named as an underwriter in, any registration statement or Regulation A offering statement filed with the Securities and Exchange Commission that, within five years, was the subject of a refusal order, stop order, or order suspending a Regulation A exemption, or is the subject of an investigation or proceeding to determine whether a stop order or suspension order should be issued?
YesNo
Is the ISO, its Directors, Executive Officers, General Partners, Managing Members, or other persons with management authority over the ISO currently the subject of any proceeding that could result in a “yes” answer to any part of the "Disclosure Information" section?
YesNo
AFFIRMATION AND SIGNATURE
The undersigned hereby affirms that s/he has executed this form on behalf of the Applicant and that the information contained herein and other information filed herewith, all of which are made a part hereof, are current, accurate and complete. The undersigned and the Applicant further represent that, to the extent that any information previously submitted is not amended, such information is currently accurate and complete.

Further, the undersigned irrevocably appoints the Bureau Chief, or successor in office, my attorney to receive service of any lawful process in any noncriminal suit, action or proceeding against him or his successor, executor or administrator which arises under this act or any rule or order hereunder after the consent has been filed, with the same force and validity as if served personally on the person filing the consent. The undersigned consents that any such action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue by service of process upon the appointee as if the undersigned had been lawfully served with process in the jurisdiction. The undersigned requests that a copy of any notice, process, pleading, subpoena or other document served hereunder be mailed to the name and address in the Contact Employee provided in the Applicant Information section as reflected in this form.
I AFFIRM
Name of Registrant:*
Affirmed by:*

First NameLast Name
Title:*
Date:*

MonthDayYear
E-mail
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NEW JERSEY INTERNET SITE OPERATOR (ISO) REGISTRATION FORM (FORM ISO)