Affidavit Of Broker-Dealer Activity Within Or From Vermont - Vermont Department Of Banking, Insurance, Securities & Health Care Administration Page 2

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I,
, acknowledge the foregoing to
be truthful with the
(Name of Principal)
full knowledge that misrepresentations or omissions of such facts to the Commissioner of
Banking, Insurance, Securities and Health Care Administration of the State of Vermont may
result in enforcement action by the Securities Division.
______________________________________
__________________
(Signature of Principal)
(Date)
Subscribed and sworn to me this ________day of _____________, 2____.
__________________________________
Notary Public
Notary's Seal Here
My Commission Expires:_______________

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