Form Dfi/dos/bdaa (Wi) - Wisconsin Broker-Dealer Activity Of Applicant
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1§551.406(1) Wis. Stats. and 4.01(2)(a), Wis. Adm. Code
STATE OF WISCONSIN
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF SECURITIES
Mail Specified Documents to: PO Box 1768
Madison, WI 53701-1768
You may fill out this form electronically. Click on the No or Yes
(608) 266-2139
box and fill in the rest of the fields. Use the Tab key to advance
TTY: ( 608) 266-8818
to the next item. When finished, you must print the completed
Internet: www.
form for submission to the Division.
Use the Reset Form button to clear all fields.
WISCONSIN BROKER-DEALER ACTIVITY OF APPLICANT
Pursuant to §551.401(1), Wis. Stats., it is unlawful for any person to transact business in Wisconsin as a broker-dealer
unless so registered under Chapter 551, Wis. Stats., except that a person who effects transactions in this state exclusively
for the account of or exclusively in offers to sell or sales as specified in §551.401(2) and (4), Wis. Stats., or section
DFI-Sec 4.10(1), Wis. Adm. Code, is not required to be so registered.
Transacting business includes effecting or attempting to effect transactions in securities and/or soliciting any person in the
state to become a customer of the broker-dealer.
The fact that a person may have transacted business as a broker-dealer in Wisconsin in violation of §551.401(1), Wis.
Stats., does not mean that a person’s Wisconsin registration application will automatically be denied.
As part of the Wisconsin Broker-Dealer Registration Application, the applicant must respond as to whether or not the
applicant has engaged in broker-dealer business in Wisconsin without being properly registered. To facilitate your
response, please complete the questionnaire below and return the completed form to this Division.
NO, this applicant is not now transacting and has never transacted broker-dealer business in Wisconsin.
YES, this applicant has transacted broker-dealer business in Wisconsin prior to this application.
The applicant agrees to stop transacting such business immediately, until properly registered.
If yes, list all transactions effected in Wisconsin:
Name & Address of
Date of
Description of
Date of Client
Name of
Total Commissions
Customer
Transaction
Transaction
Agreement
Agent
Charged
(Attach additional pages if space provided is insufficient.)
Name of Applicant ______________________________________________________________
______________________________________________________________________________
Firm’s Authorized Signatory
______________________________________________________________________________
Typed Name and Title of Signatory
Date _____________________________
Firm CRD Number____________________
This document can be made available in alternate formats
Reset Form
upon request to qualifying individuals with disabilities.
DFI/DOS/BDAA (WI) (R11/12)
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