Connecticut Broker-Dealer Supplement Form - Banking Comission - Connecticut
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3Connecticut Broker-dealer Supplement
Applicant Information
Applicant Name: __________________________________________________________________________
Exact Name of Broker-dealer Applicant as Stated in Item 1 of Form BD
IRS Number: ________________________________
Applicant’s IRS Employer Identification Number
Applicant CRD Number: ______________
Connecticut law provides that no broker-dealer may be registered without the registration of at least one
broker-dealer agent. Please list the name(s) and CRD number(s) of the agent(s) applying for Connecticut
registration through the CRD System here:
Agent Name
Agent CRD Number
Pre-Existing Clients
The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration,
that, during the two year period immediate preceding the date of its Connecticut broker-dealer
application, the applicant has not transacted business as a broker-dealer in Connecticut, and, if the
applicant is based in Connecticut, that the applicant has not transacted business as a broker-dealer in
Connecticut or from Connecticut with persons located in another jurisdiction.
The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration,
that, during the two year period immediately preceding the filing of its Connecticut broker-dealer
application, the applicant (you may check more than one box):
Has transacted business as a broker-dealer in Connecticut.
Is based in Connecticut and has transacted business as a broker-dealer from Connecticut with
persons located in another jurisdiction.
Attach a Separate Schedule Providing the Following:
•
Each customer’s name and address
•
The date(s) the transactions were effected
•
Copies of written confirmations and monthly statements
•
How each customer or client was introduced to the broker-dealer
•
The names and CRD numbers of the agent(s) who handled each transaction
•
The exclusion or exemption, if any, under the Connecticut Uniform Securities Act upon which
the applicant relied in transacting business with each customer
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