Form 260.211.1 - Application For Broker-Dealer Certificate
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1
2Mail to:
Fee: $300
State of California
File No. ____________________________
Department of Corporations
Date of Application ___________________
1515 K Street, Suite 200
Sacramento, CA 95814-4052
DEPARTMENT OF CORPORATIONS
STATE OF CALIFORNIA
APPLICATION BY NOTIFICATION
PURSUANT TO CORPORATIONS CODE SEC. 25211(b)
FOR BROKER-DEALER CERTIFICATE
(Only for Use in Connection with Applications and Amendments to Applications for Broker-Dealer Certificate Pursuant to Section
25211(b), Corporations Code (Application by Notification), and Section 260.241.4, Title 10, California Code of Regulations.)
1.
Date of Notice: ________________________________________________________________
2.
( ) Original Notice
( ) Amended Notice
3.
Name of Broker-Dealer
Address of Principal Office
_____________________________________________________________________________
4.
Name and address of officer or partner of the broker-dealer who is to receive compliance and
information communications from the Department and who is responsible for disseminating the same
within the broker-dealer's organization.
Name ____________________________
Title ___________________________
Address __________________________
Telephone (
) __________________
__________________________________
(See Corporations Code Section 25245)
5.
The following representations are made to the Commissioner of Corporations by the broker-dealer:
a.
The broker-dealer has a currently effective registration as a broker-dealer under the Securities
Exchange Act of 1934 (15 USC 78a et seq.).
b.
The broker-dealer is a member in good standing of the self-regulatory organizations checked:
( ) NYSE ( ) NYSE AMEX ( ) NYSE Arca ( ) FINRA
c.
Check the applicable box:
( )
(1)
The broker-dealer has never had a certificate as a broker-dealer, investment adviser or
agent revoked, or an application for such a certificate denied, under the Corporate
Securities Law of 1968 or any predecessor statute.
( )
(2)
The Commissioner has by order waived the denial or revocation of a certificate as a
broker-dealer, investment adviser or agent heretofore issued to the broker-dealer.
6.
Exhibits. Attach the following exhibits:
a.
A completed Customer Authorization of Disclosure of Financial Records (Form QR 500.261
(1/00), hereby incorporated by reference).
FORM 260.211.1 (Register 2009, No. 46)
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