Form Adv-W - Notice Of Withdrawal From Registration As An Investment Adviser Page 5
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9Form ADV-W
Page 2
B. Your SEC file number (if you are registered with the SEC as an investment adviser):
801- ________________
C. Your CRD number (if you have a number (“CRD number”) assigned by the FINRA’s CRD system):
__________________
If you do not have a CRD number, skip this Item 1C. Do not provide the CRD number of one of your officers,
employees, or affiliates.
D. Name and business address of contact employee:
_______________________________________________________________
(name)
(title)
_______________________________________________________________
(number and street)
_______________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
___________________________________
(area code) (telephone number)
_________________________________________________
(electronic mail (e-mail) address, if contact employee has one)
The contact employee should be an employee (not outside counsel) who is authorized to receive information and
respond to questions about this Form ADV-W.
E. Principal Office and Place of Business:
Address (do not use a P.O. Box):
_______________________________________________________________
(number and street)
_______________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
___________________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
Item 2
Status of Advisory Business
A. Have you ceased conducting advisory business in the jurisdictions from which you are
withdrawing?
Yes
No
If yes, provide the date you ceased conducting advisory business in the jurisdictions checked in the status section
above:
___________________________________
MM / DD / YYYY
If you ceased conducting advisory business in these jurisdictions on different dates, you must submit a different
Form ADV-W for each different date on which you ceased conducting advisory business.
B. Reasons for withdrawal: __________________________________________________________
______________________________________________________________________________
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