Form Sfn 53495 - Affidavit Of Broker/dealer Activity - North Dakota

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Securities Department
AFFIDAVIT OF BROKER/DEALER ACTIVITY
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 53495 (09-2002)
(701) 328-2910
Name of Applicant:
Applicant does hereby certify:
_____ 1. That the above-named Applicant has offered for sale or sold securities, solicited clients, transferred
clients, or been involved in wrap-fee programs within this state. (Attach a list of names and addresses
of North Dakota residents solicited in our state.)
_____ 2. That the above-named Applicant has not offered for sale or sold any securities, solicited clients,
transferred clients, or been involved in wrap-fee programs within this state.
_____ 3. That the above-named Applicant has offered for sale and sold securities, solicited clients, transferred
clients, or been involved in wrap-fee programs within this state pursuant to an exempt transaction.
(Please specify which exemption was relied upon):
I, on behalf of _______________________________________________________________________________ (Name of
Applicant), acknowledge the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Securities
Department of the State of North Dakota may result in administrative action by the Department.
Signature of Officer, Partner or Sole Proprietor:
Subscribed and sworn to before me this _____________ day of ______________________________________, 20 _______.
___________________________________________________
Notary Public
County of ___________________________________________
(NOTARIAL SEAL)
State of ____________________________________________
My commission expires on _____________________________
THE INFORMATION PROVIDED ON THIS AFFIDAVIT MAY BE VERIFIED WITH YOUR CLEARING FIRM. PLEASE
PROVIDE THE FOLLOWING INFORMATION REGARDING YOUR CLEARING FIRM (IF YOU HAVE A CLEARING FIRM
ARRANGEMENT):
Name of Clearing Firm:
Name of Contact Person with Firm:
Address of Firm:

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