Public Records Request Form - 2006
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1Department of Financial Institutions
PUBLIC RECORDS REQUEST
SECURITIES DIVISION
PO Box 9033
Olympia, WA 98507-9033
Securities Date Stamp
(360) 902-8760 / FAX: (360) 902-0524
PLEASE PRINT Do not send any money until you are notified of the cost
PERSON REQUESTING
Name
Company
Address
City, State, ZIP
(
)
(
)
Phone #
FAX #
Email:
NAME OF PUBLIC RECORD
.
Check document requested. Please specify which record is requested and whether the document should be the most recent date or a particular year
Name of Company or Individual
Date of Document
Offering Circular (Prospectus)
Franchise Agreement
Financial Statements
Application Form
Correspondence
Form D
CRD Report (name/CRD number)
Licensee List (specify type)
Other (specify)
CONDITIONS FOR RELEASE OR REVIEW OF PUBLIC RECORDS
Pursuant to RCW 42.56.070(9), I agree that any list of individuals provided to me will not be used for any commercial purpose by myself
or any other person I represent. I will protect the information from access by anyone who may use it for a commercial purpose.
“Commercial purpose” includes using the information for any profit-making activity.
If I wish to inspect or review record(s), I agree to the following conditions: I will not remove the records from the designated area. The
quantity of records may be limited. I will not mark or alter the records in any way. I will not destroy or deface the records in any way
including writing on, folding or folding anew if in folded form, tracing or fastening with clips or other fasteners except those that already
exist in the file. I will not cut or mutilate records in any way. I will keep the records in the order received. And I will return the records to
the department when no longer required by me and no later than the end of customary office hours on the day provided.
Signature of Person Requesting Public Document
Date
The minimum charge is $.15 per page. Under certain circumstances this fee may be waived. Please pay by check made payable to the
Washington State Treasurer. NSF checks will be subject to a $15.00 fee.
Division Contact:
Number of copies:
Cost per page: $
TOTAL DUE: $
15
.
DFI-PD-SEC-400 (10/06)
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