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Connecticut Broker Dealer Supplement - Connecticut
| Connecticut Broker Dealer Supplement Form. This is a Connecticut form and can be used in Securities Blue Sky Secretary Of State . |
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Page 1 of 2 CONNECTICUT BROKE R-DE AL ER S UPPL EMENT GENERA L 1. Exact Name of Broker-dealer Applicant as Stated in Item 1 of Form BD: 2. Applicants IRS Emp loyer Identification Number: 3. Applicants CRD Number: 4. Connectic ut law provides that no broker-dealer may be registered without the registration of at least one broker-dealer agent. To expedite our processing of your firms application, you may wish to list the name(s) and CRD number(s) of the agent(s) applying for Connecticut registration through the CRD System here: Name CRD Number CER TIFICATION CONCERNI NG PRE- EXIST ING CLIENTS [ ]The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration, that, during the two year period immediate preceding the date of its Connecticut broker-dealer application, the applicant has not transact ed business a s a broker-dealer in Connecticut, and, if the applicant is base d in Connecticut, that the applicant has not transacte d business a s a broker-dealer in Connecticut or from Connecticu t with persons located in another jurisdiction. [ ]The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registr ation, that, during the two year period immediately preceding the filing of its Connecticut broker-dealer application, the applicant (you may check more than one box): [ ] Has transa cted busin ess as a broker-dealer in Connecticut . [ ]Is based in Connecticut and has transacted business as a broker-dealer from Connectic ut with pers ons located in another jurisdiction. Attach a S eparate S chedule Providing the Following Information and Documents: * Each cu stomer s name and address * The date(s) the transactions were effected * Copies of written confirmations and monthly statements * How each custom er was introduced to the broker-dealer * How each client was introduced to the applicant The names and CRD numbers of the agent(s) who handled each transaction The exclusion or exemption, if any, under the Connecticut Uniform Securities Act upon which the applicant relied in transacting business with each custom er <<<<<<<<<********>>>>>>>>>>>>> 2Page 2 of 2 CER TIFICATION CONCERNI NG STATEMENTS OF FINANCIAL CONDITION The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration, that the statement(s) of financial condition submitted in connection with such application pursuant to Section 36b-9 of the Connecticut Uniform Secur ities Act are, to the best of the applicants own knowledge true, and that neither the principal, nor any member, partner, officer or director of the applicant, as the cas e may be, has any proprietary interest in any account classifi ed solely as that of a custom er except as follows: UNDER TAKING NOT TO TR ANS ACT BUSINESS AS A BROKER- DEALE R ABSEN T R EGIS TR ATION The undersign ed undertakes , on behalf of the aforementioned applicant for broker-dealer registration, that the applicant will not transact business a s a broker-dealer in or from Connecticut until effectively register ed as a broker-dealer in this state. EXE CUTION S ECTION The undersigned, being duly sworn, does hereb y certify, on behalf of the aforementioned applicant for broker-dealer registration under the Connecticut Uniform Securities Act that he or she is authorized to execute this Connecticut Broker-dealer Supplement on behalf of the applicant and that the information contained herein, including any schedules and supplements included herewith, is complete, true and accurate. ______________________________________________________ Print Name of Signatory: ________ Title: Subscribe d and sworn to before me this day of ____________ 20__ _. Notary Public/Commissioner of the Superior Court My Commission Expires: R ev. 5/2004
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