Application For Registration As A Municipal Securities Dealer Page 10
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13OFFICIAL USE
FORM MSD Execution Page
EXECUTION:
STATE OF ________________________________________
}
ss:
COUNTY OF _____________________________________
The undersigned, being first duly sworn, deposes and says that he or she has executed
this Form on behalf of, and with the authority of, the applicant named in item 2(a) and, if
applicant is a department or division of a bank, on behalf of, and with the authority of, the
bank named in item 2(d). The undersigned represents that the information and statements
contained herein, including exhibits attached hereto and other information filed herewith, all
of which are made a part hereof, are, to the best of the undersigned’s knowledge and belief
and on the basis of diligent inquiry, current, true, and complete. The undersigned further
represents that to the extent any information previously submitted is not amended, such
information is, to the best of the undersigned’s knowledge and belief and on the basis of
diligent inquiry, current, true, and complete.
Dated the ____________________________ day of __________________________ , 20 _____
________________________________________________________________________________
(Name of Applicant)
________________________________________________________________________________
(Manual signature of duly authorized officer)
________________________________________________________________________________
(Title)
Subscribed a
nd sworn
to before me this
____________________________
day of
____________________________ , 20____
______________________________________________________________
_________
(Notary Public)
My commission expires
:
____________________________________
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