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

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EXHIBIT III
S.D.4.C.
(Revised 1974)
COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
AGENTS TO BE CANCELED (Without Clear Records)
(Detailed information attached herewith)
NAME
ADDRESS
The information contained herewith is true to the best of this firm’s knowledge and belief.
_________________________________________________
Broker-Dealer
Date
_________________________________________________
By
(Signature)
Title

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