Form Bd Uniform Application For Broker-Dealer Registration (Page 5 of 28) in pdf

FORM BD

UNIFORM APPLICATION FOR BROKER-DEALER REGISTRATION

OFFICIAL

OFFICIAL USE

USE

ONLY

PAGE 1

(Execution Page)

Date:____________________ SEC File No: 8- __________________ Firm CRD No.: _______________

WARNING:

Failure to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep accurate books

and records or otherwise to comply with the provisions of law applying to the conduct of business as a broker-dealer would violate the

Federal securities laws and the laws of the jurisdictions and may result in disciplinary, administrative, injunctive or criminal action.

INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE CRIMINAL VIOLATIONS.

APPLICATION

AMENDMENT

Exact name, principal business address, mailing address, if different, and telephone number of applicant:

A. Full name of applicant (if sole proprietor, state last, first and middle name):

B. IRS Empl. Ident. No.:

C. (1) Name under which broker-dealer business primarily is conducted, if different from Item 1A.

(2) List on Schedule D, Page1, Section I any other name by which the firm conducts business and where it is used.

D. If this filing makes a name change on behalf of the applicant, enter the new name and specify whether the name change is of the

applicant name (1A) or

business name (1C):

Please check above.___________________________________________________________________________________________________________________

E. Firm main address: (Do not use a P.O. Box)

______________________________________________________________________________________________________________________________

(Number and Street)

(City)

(State/Country)

(Zip+4/Postal Code)

Branch offices or other business locations must be reported on Schedule E.

F. Mailing address, if different:

______________________________________________________________________________________________________________________________

G. Business Telephone Number:

___________

________________________________

(Area Code)

(Telephone Number)

H. Contact Employee:

______________________________________________________________

___________

_________________________________

(Name and Title)

(Area Code)

(Telephone Number)

EXECUTION:

For the purposes of complying with the laws of the State(s) designated in Item 2 relating to either the offer or sale of securities or commodities, the undersigned and applicant hereby certify that the applicant

is in compliance with applicable state surety bonding requirements and irrevocably appoint the administrator of each of those State(s) or such other person designated by law, and the successors in such office,

attorney for the applicant in said State(s), upon whom may be served any notice, process, or pleading in any action or proceeding against the applicant arising out of or in connection with the offer or sale of

securities or commodities, or out of the violation or alleged violation of the laws of those State(s), and the applicant hereby consents that any such action or proceeding against the applicant may be commenced

in any court of competent jurisdiction and proper venue within said State(s) by service of process upon said appointee with the same effect as if applicant were a resident in said State(s) and had lawfully been

served with process in said State(s).

The applicant consents that service of any civil action brought by or notice of any proceeding before the Securities and Exchange Commission or any self-regulatory organization in connection with the applicant’s

broker-dealer activities, or of any application for a protective decree filed by the Securities Investor Protection Corporation, may be given by registered or certified mail or confirmed telegram to the applicant’s

contact employee at the main address, or mailing address if different, given in Items 1E and IF.

The undersigned, being first duly sworn, deposes and says that he/she has executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information

and statements contained herein, including exhibits attached hereto, and other information filed herewith, all of which are made a part hereof, are current, true and complete. The undersigned and applicant further

represent that to the extent any information previously submitted is not amended such information is currently accurate and complete.

__________________________

_______________________________________________________________________________

Date (MM/DD/YYYY)

Name of Applicant

By: _____________________________________________________

__________________________________________________________________

Signature

Print Name and Title

Subscribed and sworn before me this _________ day of __________________________ , _________ by ______________________________________

Year

Notary Public