Form Ca-1 Application For Registration Or For Exemption From Registration (Page 4 of 7) in pdf

If name under which clearing agency activities are conducted is hereby amended, state name given previously: _________________

___________________________________________________________________________________________________________

Address of principal place of business:

___________________________________________________________________________________________________________

Number and Street

City

State

Zip Code

Mailing address, if different:

___________________________________________________________________________________________________________

Number and Street

City

State

Zip Code

Telephone Number: ________________

_______________________________________________

Area Code

Telephone Number

2. Name, title, mailing address and telephone number of person in charge of registrant’s clearing agency activities:

___________________________________________________________________________________________________________

Name

Title

___________________________________________________________________________________________________________

Number and Street

City

State

Zip Code

Telephone Number: ________________

_______________________________________________

Area Code

Telephone Number

3. (a) If registrant is a corporation or a national association: state date on which registrant was incorporated or organized and jurisdiction

in which incorporated or under which organized:

Date: _______________________________________ Jurisdiction: ______________________________________________

(b) If registrant is not a corporation or a national association, describe on Schedule A the form of organization under which

registrant conducts its business and identify the jurisdiction in which registrant is organized.

4. Does registrant have any arrangement with any other person under which, with respect to registrant’s clearing agency activities,

such other person processes, keeps, transmits or maintains any securities, funds, records or accounts of registrant or registrant’s

†Yes †No

participants relating to clearing agency activities?................................................................

If answer is “yes,” furnish &n Schedule A, as to each such arrangement, the full name and principal business address of the other

person and a brief summary of each such arrangement.

5. (a) With respect to clearing agency activities, please provide the following information regarding the type of insurance carried or

provided:

Type of Insurance

Yes

Amount of Coverage Amount of Deductible

1. Blanket Bond

2. Fidelity

3. Errors and Ommissions

4. Mail Policy

5. Air Courier

6. Lost Instrument

7. Other (please specify on Schedule A)

(b) If any of registrant’s clearing activities are not covered by insurance, has provision been made for self-insurance?

†Yes †No

............................................................................................................................................................

If yes, indicate on Schedule A the provisions made for self-insurance (e.g., accounting reserve or funded reserve) and the

amount thereof.

(c) (i) As a result of registrant’s clearing agency activities, is registrant exposed to loss if a participant falls to perform its

obligations to the clearing agency, any other participant or any other person?.................................... †Yes †No

(ii) If “yes,” describe on Schedule A the operational, organizational or other rules, procedures or practices (citing rules

if applicable) which result in registrant’s exposure to loss.

Form Ca-1 Application For Registration Or For Exemption From Registration Page 4

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