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Notice Form 7-R - Commodity Futures Trading Commission - National Futures Association

COMMODITY FUTURES TRADING COMMISSION

OMB Numbers 3038-0023 and 3038-0072

July 19, 2001

NATIONAL FUTURES ASSOCIATION

NOTICE FORM 7-R

Broker-Dealer Name and Business Address

NAME

ADDRESS

CITY, STATE, ZIP CODE

TELEPHONE

CRD#

(Required)

NFA ID#

(Will be assigned when application processed)

Notice of Registration as (check one):

FUTURES COMMISSION MERCHANT

INTRODUCING BROKER

Individual to whom all correspondence should be directed:

NAME

TITLE

ADDRESS

CITY, STATE, ZIP CODE

TELEPHONE

Representation and Certification

Notice broker-dealer hereby represents that 1) it is required to register only because it effects transactions in security

futures products on a contract market or derivatives transaction execution facility and 2) it will notify NFA immediately if

any information on this form, including the representation and certification, changes. Notice broker-dealer certifies that

it is registered with the Securities and Exchange Commission as a broker-dealer, that its broker-dealer registration is

not suspended, and that it is a member of a national securities association registered pursuant to Section 15A(a) of the

Securities Exchange Act of 1934.

By Officer, General Partner or Sole Proprietor:

Authorized Signature

Title

Print Authorized Signature

Date

(See reverse for instructions and notices.)

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Notice Form 7-R - Commodity Futures Trading Commission - National Futures Association