Form Adv-W - Notice Of Withdrawal From Registration As An Investment Adviser Page 6
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11Form ADV-W
Page 2
Item 1
Identifying Information
A. Your full legal name (if you are a sole proprietor, your last, first, and middle names):
______________________________________________________________________
The name you enter here must be the same as the name you entered on your last amended Form ADV. Do
not report a name change on this Form ADV-W.
B. Your SEC file number (if you are registered with the SEC as an investment adviser):
801- _______________
C. Your CRD number (if you have a number (“CRD number”) assigned by the FINRA’s CRD system):
________________
If you do not have a CRD number, skip this Item 1C. Do not provide the CRD number of one of your
officers, employees, or affiliates.
D. Name and business address of contact employee:
_________________________________________________________
(name)
(title)
_________________________________________________________
(number and street)
_________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
_______________________________
(area code) (telephone number)
____________________________________________
(electronic mail (e-mail) address, if contact employee has one)
The contact employee should be an employee (not outside counsel) who is authorized to receive
information and respond to questions about this Form ADV-W.
E. Principal Office and Place of Business:
Address (do not use a P.O. Box):
_________________________________________________________
(number and street)
_________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
_______________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
Item 2
Status of Advisory Business
A. Have you ceased conducting advisory business in the jurisdictions from which you are
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