Affidavit Of Broker-Dealer Activity Within Or From Vermont - Vermont Department Of Banking, Insurance, Securities & Health Care Administration

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Vermont Department of Banking, Insurance, Securities & Health Care
Administration
SECURITIES DIVISION
AFFIDAVIT OF BROKER-DEALER ACTIVITY WITHIN OR FROM VERMONT
I,
a principal of
(the "applicant" firm)
(Name of Principal)
being duly authorized to represent the Applicant, have thoroughly and diligently searched and
conducted a review of the Applicant's applicable books and records.
The result of this review
shows that (please check one):
That, since the date, if any, the Applicant was last duly registered as a Broker Dealer in
Vermont, by or through any of its agents, has not offered for sale or sold any securities,
solicited clients, maintained accounts, or been involved in any wrap-fee programs within
the State of Vermont.
OR
That, since the date, if any, the Applicant was last duly registered as a Broker-Dealer in
Vermont, by or through any of its agents, has offered for sale or sold any securities,
solicited clients, maintained accounts, or been involved in any wrap-fee programs within
the State of Vermont.
The activity has been conducted with
clients, from
to
(number of clients)
(start date)
(end date)
Attached is a list of all activity conducted
by the Applicant, by
within or from Vermont
or through any of its agents. The list includes:
a) Name and address of each client within or from Vermont
b) Name, home address, business address, home telephone number, business telephone
number, and Central Registration Depository or Social Security Number of each broker-
dealer representative of the Applicant that serviced each client identified in Item (a)
above.
c) Commission run for each client account identified in Item (a) above.
If the Applicant and its broker-dealer representatives relied upon an exemption from
registration, or believe to be exempt from the Vermont Uniform Securities Act, using a
separate page, identify, in writing, the exemption relied upon or explain why the Applicant
and its representatives were not subject to the registration requirements of the Vermont

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