Form 440-2785 - Non-Finra Broker-Dealer Renewal Application

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Oregon Department of Consumer & Business Services
Division of Finance & Corporate Securities
350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
NON-FINRA BROKER-DEALER RENEWAL APPLICATION
ORS 59.185
BD-
Name of licensee:
License number:
Contact person:
Phone: (
)
-
Title of contact person:
Fax:
(
)
-
The non-FINRA broker-dealer firm identified above hereby applies for renewal of its license in Oregon.
All material changes as defined in OAR 441-175-0105 have been filed with the Division of Finance and Corporate
Securities for the past year or are shown on the amended Form BD filed with this renewal application.
The name of the person who is the firm’s supervisor of operations in Oregon:
The licensee files financial statements with the SEC on Form 10K.
Yes
No
If no, please provide the name and phone number of a contact person from whom to request these statements.
VERIFICATION
I declare, under penalty of perjury, that I am
(title or position) of the licensee
and I am fully authorized to file this renewal for and on behalf of the licensee. I have read and am familiar with the
information in this renewal and with all materials or documents accompanying it. To the best of my knowledge and
belief, the information contained in this renewal and the accompanying documents is true, correct, and complete.
By (type or print name):
Date:
Signature:
Make check or money order payable to Oregon Division
Visa
MasterCard
Discover
Phone:
of Finance and Corporate Securities. If paying by credit
card, applicant must sign credit card information box.
Credit card number
Expiration date
Mail application with payment to:
DCBS — Fiscal Services
Name of cardholder as shown on credit card
P.O. Box 14610
Salem, OR 97309-0445
$
Cardholder signature
Amount
Fiscal use only: 62110/1001
Fee: $250
440-2785 (3/11/COM)

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