Broker-Dealer Questionnaire And Affidavit: Prior Sales
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1BROKER-DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES
Firm CRD No.:
Date:
Full Name of Broker-Dealer:
SEC File No.:
8-
The undersigned certifies as follows: I have conducted a thorough review into the activities of the Broker-
dealer listed above and, to the best of my knowledge within the past 36 months, the firm has not effected
non-exempt transactions in the state(s) indicated below.
Alabama
Idaho
Michigan
New York
South Dakota
Alaska
Illinois
Minnesota
North Carolina
Tennessee
Arizona
Indiana
Mississippi
North Dakota
Texas
Arkansas
Iowa
Missouri
Ohio
Utah
California
Kansas
Montana
Oklahoma
Vermont
Connecticut
Kentucky
Nebraska
Oregon
Virginia
Delaware
Louisiana
Nevada
Pennsylvania
Washington
District of Columbia
Maine
New Hampshire
Puerto Rico
West Virginia
Florida
Maryland
New Jersey
Rhode Island
Wisconsin
Georgia
Massachusetts
New Mexico
South Carolina
Wyoming
Hawaii
ALL
If any transaction were made in reliance upon an exemption, I have attached a list of those transactions. As
to those transactions, I have identified the exemption upon which the broker-dealer relied and an
explanation.
For those transaction that occurred within the past 36 months which were effected without the benefit of an
exemption. I am providing the following information:
•
The accountholder's name, address and telephone number.
•
Name of the security.
•
Date and amount of the trade, including the commission paid to the Broker-
dealer and to the Agent.
•
The Agent who effected the transaction.
I am aware that the state may verify this information with my clearing firm.
I further certify that the Broker-dealer listed above will refrain from transacting business as a Broker-
Dealer in the jurisdictions shown until registration is completed.
I acknowledge that if my response to any of the above is false or if the Broker-Dealer transacts business
during the period prior to registration, the Broker-Dealer and I are subject to sanctions pursuant to the laws
of the particular jurisdiction involved.
_________________________________________
Name of Principal (please print)
__________________________________________
Signature of Principal
Subscribed and sworn before me this ___________ day of ___________________, ______________.
County of ____________________, State of ________________________________.
My commission expires _____________________________________.
_______________________________________
Notary Public
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