Application For Registration As A Municipal Securities Dealer Page 5
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13OFFICIAL USE
FORM MSD Page 2
2. (c) Name, title, mailing address and telephone number of person to contact with respect to applicant’s municipal securities dealer
activities:
__________________________________________________________________________________________________________
Name
Title
__________________________________________________________________________________________________________
Mailing address:
Number and Street
City
State
Zip
Co
de
Telephone Number: ___________________________________________________________________
Area Code
Telephone Number
(d) If applicant is a department or division of a bank, name, principal business address, mailing address, if different, and telephone
number of bank:
Full name of bank: ________________________________________________________________________________________
__________________________________________________________________________________________________________
Address of principal place of business:
Number and Street
City
State
Zip Code
__________________________________________________________________________________________________________
Mailing address if different:
Number and Street
City
State
Zip Code
Telephone Number:_________________________________________________
__________________
Area Code
Telephone Number
(e) Applicant agrees and consents that the notice of any proceeding under the Act involving applicant may be given by sending
such notice by mail or confirmed telegram to the person named, at the address given, in response to item 2(c).
3. List below each jurisdiction in which applicant, or the bank of which applicant is a part, is filing or has filed an application for
registration or license as a municipal securities dealer or in which applicant, or the bank of which applicant is a part, is so registered
or licensed:
_______________________________________________
____________________________________________________
_______________________________________________
____________________________________________________
_______________________________________________
____________________________________________________
_______________________________________________
____________________________________________________
4. (a) Indicate whether applicant, or the bank of which applicant is a part, is a national banking association or YES NO
operated under the District of Columbia Code:
(b) If applicant is a bank, the date of applicant’s organization. If applicant is a department or division
of a bank, the date of the bank’s organization: _____________________________________________
(c) If applicant, or the bank of which applicant is a part, is a state-chartered bank, indicate whether
applicant or such bank is:
YES NO
(1) a member of Federal Reserve System:
(2) if not a member of the Federal Reserve System, insured by the Federal Deposit
YES NO
Insurance Corporation:
If any item on this page is amended, you must answer in full all other items on this page and file
with a completed page 1, and signed execution page. No Schedule required by any item on this page
need be filed with an amended item unless the Schedule itself is amended.
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