Connecticut Sales Agent/broker-Dealer Licensing Questionnaire Form
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1CONNECTICUT SALES AGENT/BROKER-DEALER LICENSING QUESTIONNAIRE
(Rev. 6/2003)
What This Form Does
The Connecticut Uniform Securities Act requires broker-dealers and agents of issuer who transact
business in or from the state to be registered. To help us with our licensing function, this form elicits
information on broker-dealers and agents of issuer involved in public and private offerings.
1.
Issuer’s Name:
_______________________________________________________
2.
Answer this Question Only If the Issuer WILL Use a Broker-dealer Firm for Connecticut Sales
a. Broker-dealer’s name and CRD number: ____________________________________________
b. Broker-dealer’s address __________________________________________________________
3.
Answer this Question If the Issuer Will NOT Use a Broker-dealer Firm for Connecticut Sales
a. Name the individual who will represent the issuer in offering or selling securities in
Connecticut. Corporations, partnerships and LLCs are not individuals.
_________________________________________________________________________________
b. The individual’s CRD number (if any) is: _________
c. Individual’s address: ______________________________________________________
d. Individual’s position with the issuer: [
] Employee [
] Partner [
] Officer
[
] Director [
] Managing Member [
] Officer of corporate general partner
[
] Other (e.g. finder) Specify _________________________________
e. Is he or she otherwise in the business of effecting securities transactions? [
] Yes [
] No
f. If the individual is a partner, officer, director or managing member of the issuer or an officer
of a corporate general partner, will the individual receive any direct or indirect remuneration
related to offers or sales of the securities in or from Connecticut? [
] Yes
[
] No
g. Will the individual be applying for agent of issuer registration? [
] Yes [
] No
h. If the individual is a broker-dealer agent who has or may receive sales compensation in
connection with the sale of the issuer’ s securities, enclose a copy of the broker-
dealer’s written approval required by Section 36b-31-6e(d) of the Regulations of
Connecticut State Agencies. [
] Copy Enclosed
[
] Not Applicable
I certify that the foregoing responses are true, accurate and complete.
__________________________________________________________________________(Sign here)
Print name of signatory, and then date this form: ______________________________________________
Position with Issuer ____________________________________________________________
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