Form 172 - Bond For Investment Adviser Page 2
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3seals this ______ day of ___________, ____.
WITNESS:
_________________________
_____________________________
_________________________
ATTEST:
_____________________________
_________________________
By___________________________
(INDIVIDUAL ACKNOWLEDGMENT)
STATE OF ___________________)
) SS.
COUNTY OF __________________)
On this ______day of ________, ____, before me, a Notary
Public within and for said county, personally appeared,
____________, to me known to be the person described in and who
executed the foregoing instrument, as Principal, and
acknowledged to me that ..he executed the same as a free act and
deed.
___________________________________
(NOTARIAL SEAL)
Notary Public, ____________________
County, ___________________________
My Commission Expires _____________
___________________________________
(CORPORATE ACKNOWLEDGMENT)
STATE OF
__________________)
) SS.
COUNTY OF __________________)
On this _____day of ________, ____, before me a Notary
Public within and for said county, personally appeared,
___________________________, who being first duly sworn, says
that ..he is the _________________________________________ of
_________________________________, Principal herein, and
executed the foregoing instrument for and in its behalf, by
authority of its Board of Directors, that the seal affixed to
the foregoing instrument is the corporate seal of said
corporation; and further acknowledged said instrument and the
execution thereof to be the voluntary act and deed of said
corporation.
_________________________________
(NOTARIAL SEAL)
Notary Public, __________________
County, _________________________
My Commission Expires ___________
_________________________________
(SURETY ACKNOWLEDGMENT)
(Corporate Officer)
STATE OF ___________________)
) SS.
COUNTY OF __________________)
On this _______day of ________, ____, before me, a Notary
Public within and for said county, personally appeared
________________, who being first duly sworn, says that ..he is
the ___________ of ___________, Surety herein, a corporation
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