Form S-4 - Application For Registration As Dealer - 2011 Page 2
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4SFN 51526 (10-2011)
Page 2 of 4
5. Describe briefly the general character of the business conducted or proposed to be conducted by the applicant. If application is being
made as an issuer-dealer, make a positive statement to the effect that the registration is sought for the limited purpose of selling the
issuer's own securities, stating the type and amount proposed to be offered and sold, and that the issuer-dealer is not, and will not
conduct a general securities business .
6. If this application is being made to register the applicant as an issuer-dealer, two of the officers of such issuer-dealer may be exempt from
the examination requirements. Please list the two officers and their titles for whom this exemption is being applied. They must be officers
and must register as an agent.
Name:
Position:
7. Attach as Exhibit B a list containing the name of each state in which the applicant is, or has been licensed or registered, or has filed an
application indicating type registration or license, date of effectiveness or anticipated effective date. If any registration or license has
been terminated, refused, canceled, suspended, or withdrawn in any state, give full details, including the date and reason for the
termination.
(If none, so state.)
8.
Attach as Exhibit C the names of all organizations of dealers or brokers of which the applicant is a member or before which any
application for membership on the part of the applicant is pending, and whether any such membership of the applicant has ever been
denied, revoked, suspended, or has been the subject of proceedings for revocation or suspension.
(If none, so state.)
9. List the names of any securities exchange of which the applicant or any of its partners, officers, directors, trustees,
members, managers, or employees is a member and whether any such membership has ever been denied, revoked, suspended, or is
the subject of proceedings for revocation or suspension.
(If none, so state.)
10.
Is applicant registered as a dealer under the Securities Exchange
Date
YES
NO
Act of 1934 or any Act adopted in amendment thereof?
Has any such registration of the applicant ever been denied, revoked,
Date
YES
NO
suspended, or is such registration now the subject of proceedings for
revocation or suspension by the Securities and Exchange Commission?
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