Indiana Broker-Dealer Cover Sheet printable pdf download

Indiana Broker-Dealer Cover Sheet

INDIANA BROKER-DEALER COVER SHEET

This cover sheet should be completed in full and returned, along with the requested documents to

the Indiana Securities Division so that your firm’s broker-dealer application may be processed.

Please type all information.

1. Name of Firm:

______________________________________________________

Contact Person:

______________________________________________________

Address of Firm: ______________________________________________________

Telephone # (

)____________________ Fax # (

)________________________

E-Mail _______________________________________________________________

CRD Number of Firm ___________________________________________________

Have you filed with the CRD to request registration in Indiana? __________________

Have you filed with the CRD to request registration in Indiana for all agents you wish

to register in Indiana? ___________________________________________________

2. Name of First Principal __________________________________________________

CRD # of First Principal _________________________________________________

Name of Second Principal _______________________________________________

CRD # of Second Principal _______________________________________________

3. Does the firm intend on having a branch office or agent in Indiana? ___YES ____NO

If YES, please attach a copy of the Certificate of Authority of a Foreign Corporation

to Transact Business in Indiana.

4. What is the firm’s fiscal year end? _________________________________________

Indiana Broker-Dealer Cover Sheet