Form X-17a-19 - Information Required Of National Securities Exchanges

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OMB APPROVAL
OMB Number:
3235-0133
UNITED STATES
Expires:
March 31, 2018
SECURITIES AND EXCHANGE COMMISSION
Estimated average burden
Washington, D.C. 20549
hours per response
0.25
FORM X-17A-19
INFORMATION REQUIRED OF NATIONAL SECURITIES EXCHANGES AND
REGISTERED NATIONAL SECURITIES ASSOCIATIONS PURSUANT TO SECTIONS 17
AND 19 OF THE SECURITIES EXCHANGE ACT OF 1934 AND RULE 17a-19 THEREUNDER
REPORT OF CHANGE IN MEMBERSHIP STATUS
1. Identify the self-regulatory organization filing this report.
AMEX
BSE
CBOE
CSE
CHX
ISE
NASD
NYSE
PCX
PHLX
2. The change in membership with the reporting self-regulatory organization is:
(a)
New Membership
(b)
Termination of Membership
(c)
Suspension of Membership
(d)
Reinstatement from Suspension
(e)
Change of Address
(f)
Other Change in Membership Status
If (b), (c), (d) or (f) give a brief description of the circumstances ___________________________________________________
_______________________________________________________________________________________________________
3. Provide the following information concerning the subject.
Present Status: (a) thru (d)
To be changed to (a) thru (d)
(a) Name _____________________________________
(a) Name ________________________________________
(b)
Corporation
Partnership
Sole Proprietor
(b)
Corporation
Partnership
Sole Proprietor
LLC
- Other ___________________
LLC
- Other ___________________
(c) SEC File No. _______________________________
(c) SEC File No. _______________________________
(d) Principal Place of Business:
(d) Principal Place of Business:
_____________________________________________
_____________________________________________
(Number and Street)
(Number and Street)
_____________________________________________
_____________________________________________
(City)
(State)
(Zip Code)
(City)
(State)
(Zip Code)
4. The subject is also a member of the:
AMEX
BSE
CBOE
CSE
CHX
ISE
NASD
NYSE
PCX
PHLX
5. The examining authority and SIPC collection agent prior to this change in membership status is:
AMEX
BSE
CBOE
CSE
CHX
ISE
NASD
NYSE
PCX
PHLX
6. Name of person completing report _______________________________ Title __________________________________
Effective Date
Telephone No ______________________ Signature _________________________________ of Change ____________
(ADVISE BROKER-DEALER OF ITS OBLIGATION TO AMEND ITS FORM BD OR FILE FORM BDW)
RESERVED FOR SEC ACTION
Examining Authority Not Changed
Examining Authority Changed
From _______________ to _______________
Signature __________________________________________________________
Date __________________________
INSTRUCTIONS ON BACK
Persons who are to respond to the collection of information
SEC 1414 (07-01)
contained in this form are not required to respond unless the
form displays a currently valid OMB control number.

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