Connecticut Broker-Dealer Supplement Form - Banking Comission - Connecticut Page 3
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3Signature
The undersigned, being duly sworn, does hereby certify, on behalf of the above Applicant for broker-
dealer registration under the Connecticut Uniform Securities Act that he or she is authorized to execute
this Connecticut Supplement on behalf of the Applicant; that the information contained herein, including
any schedules and supplements included herewith, is complete, true and accurate; and that the
Applicant will comply with the undertakings contained in this Connecticut Supplement.
_________________________________________________________
Signature of Executive Officer or individual of similar rank
Print Name of Signatory: ___________________________________
Title: ____________________________________________________
Subscribed and sworn to before me
this
day of
20
.
___________________________________________
Notary Public/Commissioner of the Superior Court
My Commission Expires:
Rev. 11/2007
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