1. (a) An issuer who effects a transaction under Section 25102(o) of the Code shall file a notice of transaction with the Commissioner not later than 30 days after the initial issuance of a security in California (Section 25008 of the Code) in that transaction. The notice shall be accompanied by the fee prescribed by Section 25608(y) of the Code.
2. (b) Each issuer (other than a California corporation) must also file a consent to service of process (Form 260.165), unless it already has a consent to service of process on file with the Commissioner.

3. (c) The following form is to be used for transactions covered by Section 25102(o) of the Code:

   (Department of Business Oversight Use Only)

   DEPARTMENT OF BUSINESS OVERSIGHT FILE NO., if any:

   Fee Paid $

   (Insert File Number(s) of Previous

   Receipt No.

   Filings Before the Department, If Any)

   FEE: $__________

   (See Corporations Code Section 25608(y) and Section 25608(e).

   The fee is based on the current market value of the securities, or in the case of options, the underlying securities.)

   COMMISSIONER OF BUSINESS OVERSIGHT STATE OF CALIFORNIA

   Notice of Issuance of Securities Pursuant to Subdivision (o) of Section 25102 of the Corporations Code

4. 1. Name of Issuer:
5. 2. State of Incorporation or Organization:

6. 3. Address of Principal Place of Business:

   Number and Street

   City

   State

   Zip Code

7. 4. The security is issued pursuant to a : (Check One)

   ( ) Purchase Plan Agreement.

   Name of Security:

   Number of Securities:

   Price Per Security: $

   ( ) Option Plan or Agreement.

   Name and Number of Options:

   Name and Number of the Underlying Securities:

   Exercise Price Per Security: $

   ( ) “Flexible” Purchase/Option Plan or Agreement.

   Name of Security/Option:

   Number of Securities/Options:

   Name and Number of the Underlying Securities:

   Price Per Security: $

8. 5. Aggregate current market value of securities sought to be sold: $

9. 6. Date of Notice:

   ( )

   Check if Issuer has a

   consent to service of process on file with the Commissioner.

   Name of Issuer

   Authorized Signature on Behalf of Issuer

   Print Name and Title of Signatory

   Name, Address and Phone Number of Contact Person:

   Instructions: Each issuer (other than a California corporation) filing a notice under Section 25102(o) must file a consent to service of process (Form 260.165), unless it already has a consent to service on file with the Commissioner.

Note: Authority cited: Sections 25102(o) and 25165, Corporations Code. Reference: Sections 25102(o), 25165 and 25608(y), Corporations Code.

History

1. New section filed 5-20-97; operative 5-20-97 pursuant to Government Code section 11343.4(d) (Register 97, No. 21).

2. Amendment of section heading, section and form filed 12-28-2000 as an emergency; operative 1-1-2001 (Register 2000, No. 52). A Certificate of Compliance must be transmitted to OAL by 5-1-2001 or emergency language will be repealed by operation of law on the following day.

3. Amendment of section heading, section and form refiled 5-2-2001 as an emergency; operative 5-2-2001 (Register 2001, No. 18). A Certificate of Compliance must be transmitted to OAL by 8-30-2001 or emergency language will be repealed by operation of law on the following day.

4. Amendment of section heading, section and form refiled 8-30-2001 as an emergency; operative 8-30-2001 (Register 2001, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-28-2001 or emergency language will be repealed by operation of law on the following day.

5. Certificate of Compliance as to 8-30-2001 order, including further amendment of subsections (a) and (c), transmitted to OAL 12-27-2001 and filed 2-7-2002 (Register 2002, No. 6).

6. Change without regulatory effect amending subsection (c) filed 8-13-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 33).