Form Sfn 51532 - Issuer Dealer Renewal Application printable pdf download

FORM S - 6

Securities Department

ISSUER DEALER RENEWAL APPLICATION

600 E Boulevard Ave Dept 414

NORTH DAKOTA SECURITIES DEPARTMENT

Bismarck ND 58505

SFN 51532 (Rev. 11-2003)

(701) 328-2910

NOTE:

Registration of Dealers and Salesmen may be renewed each year at any time not less than 15 and not more than 60 days before

NOTE: Registration of Dealers and Salesmen may be renewed each year at any time not less than 15 and not more than 60 days before May

December 31. This form is to be completed for dealer renewal.

1. Firm Name

Telephone Number

Address

City

State

Zip Code

Contact Person

2. If you have registered sales people in North Dakota, a list of those currently registered is enclosed. Please review this list for

accuracy in renewing registrations. Note: A letter of resignation must be completed for each salesman whose registration will not be

renewed and an application form (S-5) must be completed for each new registrant. Should you need an S-5 form, contact our website at

It is hereby certified that since the last dealer renewal date, the North Dakota Securities Department has been notified by this dealer in

writing of all material changes, if any, of a substantial nature that have taken place affecting the dealer, his officers, directors, partners,

salesmen, and employees. This would include any disciplinary action or other proceedings that have been taken by any federal or state

agency or by any national securities exchange or national securities association.

Yes

If "No", indicate exhibit here

It is further certified that in all cases where salesmen have left our employ for whatever reason, that a termination notice has been filed with

the North Dakota Securities Department.

Yes

5. Describe the principal types of business engaged in by the registrant and types of securities being sold.

6. Enclose payment of proper fee for renewal of dealer and salesmen as provided in the North Dakota Securities Act:

For each dealer in this state

$200.00

AND

For each salesman listed on the enclosed form

$ 60.00

Dated this ___________ day of ________________________, year __________.

Name of Registered Dealer

Signature of Person Signing for the Registered Dealer

(Corporate Seal)

Title

Form Sfn 51532 - Issuer Dealer Renewal Application