Form Com 4523 - Broker-Dealer Questionnaire And Affidavit: Prior Sales Form printable pdf download

Form Com 4523 - Broker-Dealer Questionnaire And Affidavit: Prior Sales Form

BROKER-DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES

Date: ________________________________

Full Name of Broker-Dealer: ______________________________________________________

Firm CRD No.: _______________

The undersigned Principal certifies as follows:

I have conducted a thorough review into the

activities of the Broker-Dealer listed above, and, to the best of my knowledge, within the past 36

months, the Broker-Dealer has not effected non-exempt transactions in the State of Ohio.

If any transactions were made in reliance upon an exemption, I have attached a list of those

transactions. As to those transactions, I have identified the exemption upon which the Broker-

Dealer relied and an explanation.

For those transactions that occurred within the past 36 months that were effected without the

benefit of an exemption, I am providing the following information:

•

The accountholder’s name, address and telephone number;

•

Name of the security;

•

Date and amount of the trade, including the commission paid to the Broker-Dealer and to

the Agent; and

•

The Agent who effected the transaction.

I am aware that the State of Ohio may verify this information with my clearing firm.

I further certify that the Broker-Dealer listed above will refrain from transacting business as a

Broker-Dealer in Ohio until registration is completed.

I acknowledge that if my response to any of the above is false or if the Broker-Dealer transacts

business during the period prior to registration, the Broker-Dealer and I are subject to sanctions

pursuant to the laws of Ohio.

_____________________________________________

Name of Principal (Please print)

_____________________________________________

Signature of Principal

Subscribed and sworn before me this________ day of _____________________ , 2__________.

County of ______________________________State of ________________________________

My commission expires ____________________________________

_____________________________________________

Notary Public

COM 4523 (Revised 11/07)

Form Com 4523 - Broker-Dealer Questionnaire And Affidavit: Prior Sales Form