Form S.d.4.a. - Agents To Be Renewed

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EXHIBIT I
S.D.4.A.
(Revised 1974)
COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
AGENTS TO BE RENEWED
(A separate sheet may be attached if necessary)
NAME
ADDRESS
In order to assist in determining the character and reputation of the above listed individuals,
please check below whether or not they have ever been involved in any of the following:
YES
NO
Convicted of a felony or misdemeanor involving dishonesty.
( )
( )
Sued for fraud, deceit or breach of trust.
( )
( )
Adjudicated as bankrupt.
( )
( )
Any unsatisfied judgments.
( )
( )
Denied a license to sell securities.
( )
( )
A securities license suspended or revoked.
( )
( )
Ever been permanently enjoined by any securities
( )
( )
or commodities regulatory agency.
If the broker-dealer is unable to answer any of the above with a (NO), specific information must
be given concerning the agent involved.
CERTIFICATE
The broker-dealer named in the foregoing renewal application certifies that the information
supplied is true and correct to the best of its knowledge and promises to notify the Commission
promptly with respect to any change in information heretofore given. Each individual as listed is
associated with this firm as an agent and full responsibility is accepted while he is acting in this
capacity.
_____________________________________________________
Broker-Dealer
Date
_____________________________________________________
By
(Signature)
Title

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