Form 133.36 - Request For Reduced Fees For Certain Persons Registered In Multiple Capacities

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Form
133.36
Texas State Securities Board
P.O. Box 13167
Austin, Texas 78711-3167
Request for Reduced Fees for Certain Persons Registered in Multiple Capacities
Name:
Address:
Telephone:
Date of Birth:
Social Security Number:
CRD Number:
Applicant’s Dealer or name under which applicant will conduct business as a sole proprietor
Dealer:
Applicant’s Investment Adviser or name under which applicant will conduct business as a sole
proprietor Investment Adviser:
I,
, certify that I am currently registered in
Texas as either an agent of the above named dealer or as the above named sole proprietor dealer
and that I am seeking to be or currently am registered in Texas as either an investment adviser
representative of the above named investment adviser which has less than five investment adviser
representatives or as the above named sole proprietor investment adviser who has less than five
investment adviser representatives. I hereby request that the Securities Commissioner, pursuant
to §115.8 and §116.8, grant a reduction in my registration fees. I further certify that I will notify
the Securities Commissioner, within 30 days, of any cessation of dual registration or if any of the
criteria enumerated in these Board Rules cease to be applicable.
(Signature)
Subscribed and sworn to before me the _________ day of _______________________, 2_____.
Notary Public in and for the County of
State of
(NOTARY SEAL)
My commission expires
10-26-2006

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