Você está na página 1de 1

NDMF 96-1DS

NAME RELATIONSHIP DATA MAINTENANCE FORM


STOCKHOLDERS / DIRECTORS / OFFICERS INFORMATION
(FOR DOMESTIC COMPANIES ONLY)

SEC NUMBER /_D__


/_1_/_9_/_9_/_9_/_0_/_1_/_1_/_5_/_2_/ /___/___/___/___/___/___/
TRANSACTION DATE

FILL UP INSTRUCTIONS: Type or print leginly. Light shaded boxes are to be filled up by SEC.
COMPANY NAME
TIERONE COMMUNICATIONS INTERNATIONAL INC. (formerly 3G COMMUNICATIONS INTERNATIONAL INC.)
STOCKHOLDERS/DIRECTORS/OFFICERS (Use additional sheets, if necessary. Fill up one line per relationship.)
NAME (MM/DD/YYYY)
RELN SEC NO. / NAT'L RELATIONSHIP SHR SHR NO. OF AMOUNT SUBSCRIBED
(Company Name, if company) NATIONALITY PERIOD START
STATUS BITRTHDATE CODE CODE TYPE SHARES
(Last Name, First Name, MI, Maiden Surname, if person) BRD INC'R OFR PAID-UP CAPITAL PERIOD END
100,000.00 08/01/2016
E JUSTINO A. CABAZARES JR. Filipino C S N COMMON 1,000
6/26/1949 25,000.00
7,363,200.00 08/01/2016
E JONATHON B. STEVENS Australian M S PRE COMMON 73,632
8/20/1954 2,620,000.00
8,223,200.00 08/01/2016
E LESLIE F. STEVENS Filipino M S CFO COMMON 82,232
12/17/1985 2,055,800.00
100,000.00 08/01/2016
E MARIA LUZ C. ANTIGA Filipino M S COS COMMON 1,000
8/29/1958 25,000.00
50,000.00 08/01/2016
E RICHARD J. STEVENS Australian M S N COMMON 500
9/5/1982 50,000.00
925,200.00 02/01/2017
N LELAND R. WARNER Australian N S N COMMON 9,252
7/14/1943 925,200.00
40,406,400.00 12/01/2016
N BENTLEY HOUSE INTERNATIONAL CORP. Filipino N S N COMMON 404,064
A199600569 10,101,600.00

CERTIFIED CORRECT: ___________________________________________________ POSITION: _____________________________________


(Signature over printed name)
DATE: __________________________________________

PROCESSING ATTORNEY PROCESSING EXAMINER DATA CONTROL CLERK: DATA ENCODER:


DATE RECEIVED DATE REVIEWED: DATE REVIEWED: DATE ENCODED:

INSTRUCTION FOR FILLING UP THE COLUMNS:


BOARD (BRD) INCORPORATOR (INC'R) OFFICER (OFR)
RELATIONSHIP STATUS INDICATOR: INDICATOR: INDICATOR:
A - NEW IF THE NAME HAS NOT PREVIOUSLY BEEN SUBMITTED TO THE SEC C - CHAIRMAN I - INCORPORATOR PRE - PRESIDENT LEG - LEGAL COUNSEL
E - EXISTING, IF THE NAME HAS PREVIOUSLY BEEN SUBMITTED TO THE SEC M - MEMBER S - STOCKHOLDER CEO - CHIEF EXECUTIVE OFFICER AUD - EXTERNAL AUDITOR
D - IF THE NAME SHOULD NOT HAVE BEEN SET-UP N - NIETHER N - NOT APPLICABLE CFO - TREASURER GOV - GOVERNMENT OFFICIAL
COO - CHIEF OPERATION OFFICER SLS - OTHERS
COS - CORPORATE SECRETARY OTH - OTHERS
N - NONE

Você também pode gostar