Form Vt-1 - Invesment Adviser And Federal Covered Investment Adviser - 2013 Page 4
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46.
By executing this form, the undersigned, in his or her individual capacity and on behalf of the above-named
applicant firm hereby swears and affirms that all information on this form and all materials filed in
connection with it are true, correct and complete. The undersigned stipulates, recites, acknowledges and
agrees that if the Vermont Securities Division finds that any information contained in this application or in
an amendment to this application is false, such finding shall constitute a violation of 9 V.S.A. § 5505.
Signed: _____________________________________________ Date: ___________________________
Authorized Signatory of Applicant Firm
_______________________________________________________________________________
Typed Name and Title of Signatory
Please mail completed form to: Department of Financial Regulation, Attn: Securities Division, 89
nd
Main Street, 2
Floor Montpelier, VT 05602
Rev 3/25/2013
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