Form Bd Uniform Application For Broker-Dealer Registration (Page 6 of 28) in pdf

FORM BD

OFFICIAL

OFFICIAL USE

USE

Applicant Name:______________________________________________________________________

ONLY

PAGE 2

Date:____________________

Firm CRD No.: _______________

2. Indicate by checking the appropriate box(es) each governmental authority, organization, or jurisdiction in which the applicant is

registered or registering as a broker-dealer.

If applicant is registered or registering with the SEC, check here and answer Items 2A through 2D below.

YES NO

A. Is applicant registered or registering as a broker-dealer under Section 15(b) or Section 15B of the

Securities Exchange Act of 1934? ..................................................................................................................................

B. Is applicant registered or registering as a broker-dealer under Section 15(b) of the Securities Exchange

Act of 1934 and also acting or intending to act as a government securities broker or dealer? ..................................

C. Is applicant registered or registering solely as a government securities broker or dealer under Section

15C of the Securities Exchange Act of 1934? ................................................................................................................

Do not answer “yes” to Item 2C if applicant answered “yes” to Item 2A or Item 2B.

D. Is applicant ceasing its activities as a government securities broker or dealer? .........................................................

If applicant answers “yes” to Items 2A and 2D, applicant expressly consents to the withdrawal of its registration

as a government securities broker or dealer under Section 15C of the Securities Exchange Act of 1934. See “Instructions.”

___________________________________

AMEX

BSE

CBOE

CHX

NSX

FINRA

NQX

NYSE

PHLX

ARCA

ISE

OTHER (specify)

Alabama

Hawaii

Michigan

North Carolina

Texas

Alaska

Idaho

Minnesota

North Dakota

Utah

Arizona

Illinois

Mississippi

Ohio

Vermont

Arkansas

Indiana

Missouri

Oklahoma

Virgin Islands

California

Iowa

Montana

Oregon

Virginia

Colorado

Kansas

Nebraska

Pennsylvania

Washington

Connecticut

Kentucky

Nevada

Puerto Rico

West Virginia

Delaware

Louisiana

New Hampshire

Rhode Island

Wisconsin

District of Columbia

Maine

New Jersey

South Carolina

Wyoming

Florida

Maryland

New Mexico

South Dakota

Georgia

Massachusetts

New York

Tennessee

A. Indicate legal status of applicant.

Corporation

Sole Proprietorship

Other (specify) _________________________________

Partnership

Limited Liability Company

B. Month applicant’s fiscal year ends: _______________

C. If other than a sole proprietor, indicate date and place applicant obtained its legal status (i.e., state or country where incorporated,

where partnership agreement was filed, or where applicant entity was formed):

State/Country of formation: ____________________________________ Date of formation: ___________________________

(MM/DD/YYYY)

Schedule A and, if applicable, Schedule B must be completed as part of all initial applications. Amendments to these schedules

must be provided on Schedule C.

4. If applicant is a sole proprietor, state full residence address and Social Security Number.

Social Security Number: __ __ __ – __ __ __ – __ __ __ __

__________________________________________________________________________________________________________________

(Number and Street)

(City)

(State/Country)

(Zip+4/Postal Code)

Is applicant at the time of this filing succeeding to the business of a currently registered broker-dealer?

YES NO

Do not report previous successions already reported on Form BD. .....................................................................................

If “Yes,” contact CRD prior to submitting form; complete appropriate items on Schedule D, Page 1, Section lll.

6. Does applicant hold or maintain any funds or securities or provide clearing services for any other broker or dealer? ...

7. Does applicant refer or introduce customers to any other broker or dealer? .....................................................................

If “Yes,”complete appropriate items on Schedule D, Page 1, Section IV.

Form Bd Uniform Application For Broker-Dealer Registration Page 6

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