Oregon Broker-Dealer Affidavit Form - Oregon Department Of Consumer And Business Services

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Oregon Department of Consumer and Business Services
Division of Finance and Corporate Securities
350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
OREGON BROKER-DEALER AFFIDAVIT
ORS 59.165, ORS 59.175
Date:
Full name of broker-dealer:
Firm CRD number:
I,
, being first duly sworn upon oath, depose and say based on
(Printed name of affiant)
my personal knowledge, information, and belief:
1. I am employed by:
(applicant) as its
(title).
2. I am authorized to execute this Affidavit on behalf of the applicant.
3. The applicant has applied to be licensed as a broker-dealer firm with the director of the Oregon Department of
Consumer and Business Services, Division of Finance and Corporate Securities (the director).
4. I acknowledge that the director wishes to determine whether the applicant has engaged in the offer and/or sale of
securities in Oregon. I have conducted a review of the applicant’s records and made diligent inquiry in this regard.
5. I understand that this affidavit constitutes a statement to the director pursuant to ORS 59.245(2), and that filing a
false statement to the director is, pursuant to ORS 59.135(4) and ORS 59.451, a violation of the Oregon Securities
Law and grounds for action against the affiant and the applicant.
6. The affiant and the applicant hereby certify:
A. The applicant, by or through any of its securities salespersons, has made NO offers or sales of securities in the
state of Oregon and will not engage in the securities business in Oregon until duly licensed with the director.
B. The applicant, by or through any of its securities salespersons, has offered or sold securities in Oregon, and
attached to this affidavit is a listing of the names, addresses, and phone numbers of all Oregon customers;
transaction dates; descriptions of the Oregon transactions; specific exemptions relied upon, if any, for each
transaction; and the amount of commissions generated from each Oregon customer.
Dated this
day of
, 20
.
(Signature of affiant)
(Printed name of affiant)
SUBSCRIBED AND SWORN to before me this
day of
, 20
.
(Signature of notary public)
(Printed name of notary public)
County of:
Notary public for the state of:
My commission expires:
440-4861 (9/09/COM)

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