OMB APPROVAL
U.S. Securities and Exchange Commission
Washington, DC 20549
OMB Number:
3235-0328
Expires:
January 31, 2017
Estimated average burden
hours per response:
0.15
FORM ID
UNIFORM APPLICATION FOR ACCESS CODES TO FILE ON EDGAR
PART I—APPLICATION FOR ACCESS CODES TO FILE ON EDGAR
Name of applicant
(Applicant’s name as specified in its charter, except, if individual, last name, first name, middle name, suffix [e.g., “Jr.”])
Mailing Address or Post Office Box No.
City
State or Country
Zip
Telephone number
(include Area and, if Foreign, Country Code)
Applicant is (see definitions in the General Instructions):
☐Individual
☐Municipal Securities Dealer
(if you check this box, you must also check another
box that appropriately describes you)
☐Clearing Agency
☐Nationally Recognized Statistical Rating Organization
☐Filer
☐Non-Investment Company Applicant under the
Investment Company Act of 1940
☐Filing Agent
☐Security-Based Swap Data Repository
☐Institutional Investment Manager (Form 13F Filer)
☐Security-Based Swap Dealer and Major Security-Based
Swap Participant
☐Investment Company, Business Development
☐Security-Based Swap Execution Facility
Company or Insurance Company Separate Account
☐Large Trader
☐Training Agent
☐Municipal Advisor
☐Transfer Agent
PART II—FILER INFORMATION (To be completed only by filers that are not individuals)
Filer’s Tax or Federal Identification Number
(do not enter Social Security Number)
Doing Business As
Foreign Name
(if Foreign Issuer Filer and applicable)
Primary Business Address or Post Office Box No.
(if different from mailing address)
City
State or Country
Zip
State of Incorporation
Fiscal Year End (mm/dd)
PART III—CONTACT INFORMATION (To be completed by all applicants)
Person to receive EDGAR Information, Inquiries and Access Codes
Telephone Number
(Include Area and, if Foreign, Country Code)