Form Br - Uniform Branch Office Registration Form Instructions Page 7
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9Rev. Form BR (04/2014)
State
Enter the state of the location (or locations, if more than one) of the books and
records for this branch office.
Country
Enter the country of the location (or locations, if more than one) of the books and
records for this branch office.
Postal Code
Enter the postal code of the location (or locations, if more than one) of the books
and records for this branch office.
Contact Information
Name
Enter the name of the individual that can be contacted regarding information on the
books and records for this branch office.
Daytime Telephone Number
Enter the daytime telephone number of the individual that can be contacted
regarding information on the books and records for this branch office.
Email Address
Enter the email address of the individual that can be contacted regarding information
on the books and records for this branch office.
7. BRANCH OFFICE WITHDRAWAL
If you are withdrawing a pending application, complete the following
information:
Date of Withdrawal
Enter the month, day, and year of withdrawal.
Reason for Withdrawal
Enter the reason for withdrawal.
Contact Information
Name
Enter the name of the individual that can be contacted regarding information on the
withdrawal of this branch office.
Daytime Telephone Number
Enter the daytime telephone number of the individual that can be contacted
regarding information on the withdrawal of this branch office.
Email Address
Enter the email address of the individual that can be contacted regarding information
on the books and records for this branch office. This field is optional.
8. SIGNATURE
Please Read Carefully
All signatures required on this Form BR filing must be made in this section. A
“signature” includes a manual signature or an electronically transmitted equivalent.
For purposes of an electronic form filing, a signature is effected by typing a name in
the designated signature field. By typing a name in this field, the signatory
acknowledges and represents that the entry constitutes in every way, use, or aspect,
his or her legally binding signature.
Signature of Appropriate Signatory. Enter the name of the Appropriate Signatory.
The name must be typed or printed (if paper filing) as it appears in signature form.
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