FORM S - 6
ISSUER DEALER RENEWAL APPLICATION
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 51532 (Rev. 11-2003)
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
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.
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.
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
For each salesman listed on the enclosed form
Dated this ___________ day of ________________________, year __________.
Name of Registered Dealer
Signature of Person Signing for the Registered Dealer