Form S-4 - Application For Registration As Dealer - 2011

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Form S-4
Securities Department
600 East Boulevard
Bismarck, ND 58505
SFN 51526 (10-2011)
(701) 328-2910
Pursuant to the provisions of Section 10-04-10 of the North Dakota Securities Act of 1951, as amended, application is made for registration
as a dealer:
Note: The registration fee for each dealer is $200
1. Name of Applicant
Telephone Number
ZIP Code
2. Form of Business Organization
Date of Organization
State of Incorporation
3. Attach as Exhibit A the names and business addresses of all members, partners, officers, directors, trustees, managers, or
supervisory persons of the applicant.
a. List any securities qualifications examination that may have been taken by any of the persons listed in Exhibit A to
include the name of the examination, date taken, and grade attained.
b. A statement setting forth in chronological order the occupational activities of each such partner, member, officer,
director, trustee, or manager for the past ten years.
c. In the case of a new dealer, include the investment experience of those listed in (a).
4. Addresses of all branch offices and name of person in charge of each in this state:


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