Form S.d.4.b - Renewal Application - Commonwealth Of Virginia

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EXHIBIT II
S.D.4.B.
(Revised 1974)
COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
AGENTS TO BE CANCELED (Records Clear)
(A separate sheet may be attached if necessary)
NAME
ADDRESS
To the best of this firm’s knowledge, the record of each of these individuals is clear.
_________________________________________________
Broker-Dealer
Date
_________________________________________________
By
(Signature)
Title

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