Connecticut Supplement State-Registered Investment Advisers Application Form Page 3
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3Foreign Compliance Certification (Applicants Not Having a Connecticut Place of Business)
Check here if the Applicant does not have a Connecticut principal place of business and will not be
filing a Statement of Financial Condition with Connecticut.
The Applicant represents that: (1) The Applicant is licensed or registered as an investment adviser in
the state where it maintains its principal place of business; (2) the Applicant is, and will remain in
compliance with the net capital and/or bonding requirements of the state where it maintains its principal
place of business; (3) the Applicant is, and will remain in compliance with all applicable books and
records requirements of the state where it maintains its principal place of business; and (4) in the event
the Applicant should no longer be licensed or registered as an investment adviser in the state where it
maintains its principal place of business, the Applicant recognizes that it will become subject to
Connecticut capitalization requirements for investment advisers and to any supplementary books and
records requirements applicable to investment advisers having their principal place of business in this
state.
Signature
The undersigned, being duly sworn, does hereby certify, on behalf of the above Applicant for
investment adviser registration under the Connecticut Uniform Securities Act that he or she is
authorized to execute this Connecticut Supplement on behalf of the Applicant and that the information
contained herein, including any schedules and supplements included herewith, is complete, true and
accurate.
_________________________________________________________
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. 5/2008
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