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Affidavit Of Broker-Dealer Activity - Vermont Department Of Banking, Insurance, Securities & Health Care Administration

Vermont Department of Banking, Insurance, Securities & Health Care Administration

SECURITIES DIVISION

AFFIDAVIT OF BROKER-DEALER ACTIVITY

I, _____________________________ do hereby swear and affirm that I am a principal of

_______________________________________ ("the applicant") and that I am able to and do hereby

represent on behalf of the applicant, after having thoroughly and diligently searched all applicable

records, as follows (use attachments as necessary):

(Please place a check next to the appropriate response.)

_____ 1.

That the above-named applicant by or through any of its agents has offered for sale or

sold securities, solicited clients, maintained accounts, or been involved in wrap-fee

programs within the State of Vermont, and all pertinent information relating to said

activity is attached to this affidavit, including names and addresses of residents,

transaction dates, a description of said transactions, and the amount of commissions

generated from each customer.

_____ 2.

That the above-named applicant by or through any of its agents has not offered for sale

or sold any securities, solicited clients, maintained accounts, or been involved in wrap-

fee programs within the State of Vermont.

_____ 3.

That the above-named applicant by or through any of its agents has offered for sale and

sold securities, solicited clients, maintained accounts, or been involved in wrap-fee

programs within the State of Vermont pursuant to an exempt transaction (please specify

which exemption was relied upon: __________________________________).

I, on behalf of the above-named applicant, acknowledge the foregoing to be truthful with the full

knowledge that misrepresentations of such facts to the Commissioner of Banking, Insurance and

Securities of the State of Vermont may result in administrative action by the Securities Division.

___________________________________

(Signature of Officer, Partner or Sole Proprietor)

___________________________________

(Typed name and title)

Subscribed and sworn to before me this _____ day of __________, ______.

___________________________________

(Notary Public)

(Place seal here)

My commission expires: ________________

On-line 3/02

Affidavit Of Broker-Dealer Activity - Vermont Department Of Banking, Insurance, Securities & Health Care Administration