The form is from an SEC filing of Golden Queen Mining Co. Ltd. which, as of the date of the filing, was publicly traded on the Toronto Stock Exchange (TSE) (Symbol: GQM) and over-the-counter in the U.S. (Symbol: GQ MNF), and had a market capitalization of in excess of $100 million back then. Here is their website if you want to check them out: www.goldenqueen.com
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This form is dated September 15, 2014 and was originally filed with the SEC on September 16, 2014.