Affidavit For Waiver Of Examination printable pdf download

S.A.3

(Rev. 7/99)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

AFFIDAVIT FOR WAIVER OF EXAMINATION

Pursuant to 21 VAC 5-80-130 B

State of _____________________________________

County/City of ________________________________, to wit:

The undersigned, having been duly sworn, deposes and says:

My name is ______________________________________________________________.

My CRD number is ________________________________________________________.

The name of the investment advisory with which I am, or will be connected is __________

________________________________________________________________________.

The CRD number of this investment advisor is __________________________________.

I am, and have been for at least the five years immediately preceding the date on which

my application for registration was filed, actively engaged in the investment advisory

business.

I have been for at least the two years immediately preceding the date on which my

application for registration was filed the president, chief executive, chairman of the board

of directors, or managing partner, member, trustee or similar functionary, of an investment

advisor actively engaged in the investment advisory business.

The investment advisor(s) referred to in subdivision 6, above, have, or had during my

tenure as president, chief executive officer, chairman of the board of directors, or

managing partner, member, trustee or similar functionary, at least forty million dollars

under management.

I have read and am familiar with the investment advisor and investment advisor

representative provisions of the Virginia Securities Act (§ 13.1 501 et seq. of the Code of

Virginia) and provisions of 21 VAC 5-80-10 - 240 of this Commission’s Securities Act

Rules.

None of the questions in Item 22 (disciplinary history) on my Form U-4 have been, or need

be, answered in the affirmative.

_____________________________________

Signature of the Affiant

Subscribed and sworn to before me, a Notary Public, this _________________________ day of

______________________________, _______.

_______________________________(SEAL)

Signature of the Notary Public

My commission expires:_________________________

INSTRUCTIONS

This form must be filed with the Division of Securities and Retail Franchising. Form U-4 (or any

amendment) and any required fee must be filed with the NASA/NASD Central Registration

Depository system.

Affidavit For Waiver Of Examination