Transaction Certification Form - District Of Columbia printable pdf download

Transaction Certification Form - District Of Columbia

Department of Insurance and Securities Regulation

Thomas E. Hampton

Commissioner

TRANSACTION CERTIFICATION

___________________________________

Date: ________________________

Broker-Dealer Name & CRD #

Please respond to one of the following which pertains to transactions effected within the

District of Columbia or with District of Columbia residents prior to registration under the

District of Columbia Securities Act (“Act”).

If your firm is claiming exemption from registration under the Act, please indicate

the specific section pertaining to the exemption that your firm is claiming in the

space below.

No securities transactions have been effected on behalf of District of Columbia

residents or within the District of Columbia while not effectively licensed under

the Act.

If your firm has effected transactions on behalf of District of Columbia residents

or within the District of Columbia while not effectively licensed under the Act,

please provide the following information:

a list of all transactions including the names, addresses, and telephone

numbers of clients involved in the transactions effected while not licensed

in the District of Columbia; and

order tickets and confirmations of any trades executed during the

aforementioned time period.

_______________________________________

B/D Authorized Person & Date

810 First Street, NE, 6

Floor•Washington, DC•20002•Tel: (202) 442-4934•Fax: (202) 535-1199

Maurice.goff@dc.gov

Transaction Certification Form - District Of Columbia