Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
Solicitation of
Interest Form
Name of Company:
Street Address of Principal Office:
City: State: ZIP:
Telephone Number: Date of Incorporation/Formation:
Amount of Proposed Offering: Name of Chief Executive Officer:
This is a Solicitation of Interest only. No money or other consideration is being solicited and none will be accepted.
No sales of the securities will be made or commitment to purchase accepted until the delivery of a final offering statement that includes
complete information about the issuer and the offering.
An indication of interest made by a prospective investor involves no obligation or commitment of any kind.
This Solicitation of Interest is being made pursuant to an exemption from registration under federal and state securities laws. No sale may
be made until the offering statement is qualified by the SEC and is registered in this state.
Neither federal nor state authorities have confirmed the accuracy or determined the adequacy of this document or any other document
presented to you in connection with this Solicitation of Interest.
1. This company:
❏ Has never conducted business operations.
❏ Is in the development stage.
❏ Is currently conducting business operations.
❏ Has shown a profit for the last fiscal year.
❏ Other (specify)
2. Type(s) of business the company engages in or proposes to engage in, including what products or goods are or will be produced or
services that are or will be rendered:
3. Describe how these products or services are or will be produced or rendered and how and when the company intends to carry out
its activities:
4. Describe how the company intends to use the proceeds of the proposed offering:
5. Provide the following information for all officers and directors or persons occupying similar positions (attach a separate sheet):
• Name
• Title
• Office Street Address
• Telephone Number
• Employment History (employers, titles, dates of positions held during the past five years)
• Education (degrees, schools, dates)
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 333.1
