Investment Adviser Representative Examination Affidavit
1. Name:
2. Address:
3. Have you obtained a passing score on the Uniform Investment Adviser Law Examination (Series
65 examination)?
Yes
No
4. Have you obtained a passing score on the General Securities Representative Examination (Series
7 examination) and the Uniform Combined State Law Examination (Series 66 examination)?
No
Yes
5. Were you registered as an investment adviser representative in any jurisdiction in the United
States on July 1, 2000 and for two (2) consecutive years prior to that date?
Yes
No
6. Have you ever been found to have violated any state or federal securities law?
Yes
No
If the answer to this question is "yes", provide a detailed description of the findings on a separate
sheet.
7. If you hold one or more of the following professional designations, check each that applies:
Certified Financial Planner (CFP) awarded by the International Board of Standards and
Practices for Certified Financial Planners, Inc.
Chartered Financial Consultant (ChFC) awarded by the American College, Bryn Mawr,
Pennsylvania.
Personal Financial Specialist (PFS) awarded by the American Institute of Certified
Public Accountants
Chartered Financial Analyst (CFA) awarded by the Institute of Chartered Financial
Analysts.
Chartered Investment Counselor (CIC) awarded by the Investment Counsel Association
of America, Inc.
I, ______________________________, hereby depose and say that the information provided herein
is true and accurate.
______________________________
Signature
SWORN TO AND SUBSCRIBED before me this _____ day of _________________, 20___
______________________________
Notary
My commission expires on: ____________________