State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator Page 7

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Applicant full legal name (last, first, middle): _____________________________________________________
5. RESIDENTIAL HISTORY (list residential history for previous ten (10) years, leaving NO gaps):
From
To
Street Address
City
State or
Zip + 4
Country
(MM/YYYY)
(MM/YYYY)
Province
Postal Code
(
6. EMPLOYMENT HISTORY
list employment history for previous ten (10) years, leaving NO gaps, and indicate whether the
employment is financial service-related.):
From
To
Employer
Position Held
City
State or
Country
YES or
(MM/YYYY)
(MM/YYYY)
(company name)
Province
NO?
Use Additional Sheets as Necessary
(Principal Manager Applicants must include a description of any relevant employment, including a detailed description of duties
performed and the name and contact information for the person you reported to)
State Form 49718 (R5 / 6-08) / Form LB 4
Page 7 of 10

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