§551.32(1) and (8), Wis. Stats., and s. DFI-Sec 4.01(2) and 4.07, Wis. Adm. Code
STATE OF WISCONSIN
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF SECURITIES
You can fill out this form online by clicking on Line 1, filling in
th
345 West Washington Ave., 4
Fl.
the required information, and using the TAB key to advance to
PO Box 1768
the next question. For phone and Social Security numbers, just
Madison, WI 53701-1768
enter numbers with no hyphens. You must then print out the
(608) 266-2139
TTY: (608) 266-8818
completed form for submission to the Division. Use the RESET
Internet:
button at the bottom to clear all fields.
NON-FINRA MEMBER BROKER-DEALER AND
AGENT LICENSE RENEWAL APPLICATION
All Wisconsin Broker-Dealer licenses expire on December 31st of each year.
This license renewal form must be received by the Division by NOT LATER THAN DECEMBER
1ST. If the renewal form is not received by December 1st, a delinquent filing fee of $100 shall be
charged pursuant to s. DFI-Sec 7.01(6) (f), Wis. Adm. Code.
A record receipt of your application will be provided if you enclose a self-addressed, postage-paid
envelope.
This document can be made available in alternate formats upon request to qualifying individuals with
disabilities.
This form is required under Section 551.32(1) Wis. Stats. Refusal to provide this information may
result in the denial of the license renewal. Personally identifiable information on this form may be
matched against tax information, outstanding child and family support data and law enforcement
agencies.
If you have any questions concerning this renewal, please feel free to contact the Licensing &
Compliance staff at (608) 266-2139.
The undersigned broker-dealer makes application to the Division of Securities for renewal of the license
authorizing it to transact securities business in Wisconsin for the calendar year 2008. The application is
accompanied by the filing fee of $200.00, $30.00 for each branch office located in Wisconsin and $30.00 for
each agent license renewed. The applicant agrees to pay any expense reasonably attributable to any
examination of its business or personnel which the Administrator deems necessary with respect to this
application.
The applicant reaffirms the statements made in its application for initial license as a
broker-dealer except as noted on this renewal application, and makes the following statements concerning its
securities business and personnel in Wisconsin:
Exact name, principal business address, mailing address, if different, and telephone number of
applicant:
Full Name of applicant (if sole proprietor, last name, first name, and middle initial)
Last name
First name
Middle
Initial
DFI/DOS/BDR(WI) (R10/07)
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