Form U-1 - Uniform Application To Register Securities Page 4
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5U-1 Part 2
Date: _____________________________
__________________________________
(Name of Applicant)
BY:
__________________________________
(Name and Title)
STATE OF ________________________
COUNTY OF ______________________
The undersigned, ___________________________________________________________________,
being first duly sworn, deposes and says:
That he/she has executed the foregoing application for and on behalf of the applicant named therein; that
he/she is _____________________ of such applicant and is fully authorized to execute and file such
application; that he/she is familiar with such application; and that to the best of his/her knowledge,
information and belief the statements made in such application are true and the documents submitted
therewith are true copies of the originals thereof.
____________________________________
(Name of Applicant)
Subscribed and sworn to before me this _________ day of ____________
(Notarial Seal)
___________________________________________
NOTARY PUBLIC
In and for the County of _______________________ State of _____________________
My Commission Expires: _____________
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