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Application For Registration As Agent Under An Issuer-Dealer A - Nebraska
| Application For Registration As Agent Under An Issuer-Dealer Form. This is a Nebraska form and can be used in General Blue Sky Secretary Of State . |
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STATE OF NEBRASKA BUREAU OF SECURITIES - DEPARTMENT OF BANKING AND FINANCE APPLICATION FOR REGISTRATION AS AGENT UNDER AN ISSUER-DEALER The undersigned hereby makes application for registration as an Agent in securities within the State of Nebraska. The facts herein stated are tr ue andconstitute a fair and complete statement of all material facts relating to this applicant. 1. Name of applicant 2. Social Security Number 3. Home address 4. Home phone number 5. Name of firm 6. Business address 7. Business phone 8. Date of employment 9. Educational History: NAME AND ADDRESS OF INSTITUTION FROM TO DID YOU DEGREE (STREET, CITY, STATE, ZIP CODE) MO. YR. MO. YR. GRADUATE 10. Employment history: The following is a complete, consecutive statement of my business histor y for the past ten years starting with my current position. (All time must be accounted for including self-employment, unemployment, part-time securit ies, commodities, insurance and real estate, industries or related posit ions and all military service.) NAME OF EMPLOYER AND COMPLETE ADDRESS FROM TO POSITION REASON FOR FULL OR (STREET, CITY, STATE, ZIP CODE) MO. YR. MO. YR. HELD LEAVING PART-TIME11. In what states is applicant now licensed or registered to sell se curities? 12. In what states has applicant ever been licensed to sell securitie s? (Specify states, dates of registration) 13. What experience does the applicant have in the sale of securities ? 14. List all companies for which the applicant has sold securities. 15. In what manner will the applicant attempt to make sale? (i.e, by telephone, in person. by mail, etc.) IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, ATTACH COMPLETE DETAILS: 16. Are you now, or have you ever been licensed to sell insurance? 17. Are you now, or have you ever been licensed to sell real estate? 18. Have you ever had denied, suspended, or revoked a license, permit , certificate, registration or membership required to engage in securities, commodities, insurance or other business or profession? American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 219. Are you now, or have you ever been suspended, expelled, fined, ba rred, censured or otherwise disciplined by an employer in a securities, commodities, insurance or real estate industry? 20. Have you ever been charged with fraudulent acts or violations of any laws in connection with the sale of securities? 21. Has the applicant ever been a subject in connection with a formal complaint, proceeding or investigation brought by the National Association of Securities Dealers, Securities and Exchange Commission or any other state for violations of their securities laws?...22. Has any permanent or temporary injunction been entered against yo u or any broker-dealer, insurer, investment advisor or commodities firm with which you were associated in any capacity at the t ime such injunction was entered? ....................................23. In your previous business connections or employment, have you eve r been: a. a subject of a major complaint or legal proceeding or, .......... ........................................................................ ............................... b. discharged or requested to resign by an employer because of dishon est or unethical acts alleged to have been committed by you ................................................. ........................................................................ ..........................................24. Are you currently bonded? If yes, specify insurance co. and amoun t ..................................................................... ..............................25. Has applicant ever been refused a surety bond? ................. ........................................................................ ..........................................26. Has a surety company ever paid out any funds on your coverage or cancelled your bond? .................................................. ..............27. Have you ever been: a. Arrested or indicted for any felony or misdemeanor involving the p urchase, sale, or delivery of any security, or arising out of the conduct of the business of a broker-dealer, fiduciary, invest ment company, investment adviser, underwriter, bank, trust company, insurance company or other financial institution, or invo lving any crime in which violence or threats of violence against any person, dishonesty, the wrongful taking of any prop erty, or any manner of fraud was a factor, or involving conspiracy to commit any of the foregoing? .................. ........................................................................ .......................... b. Convicted of, or pleaded nolo contendere to, any felony or any misdemeanor, except minor traffic offenses? ..... ....................28. Are you currently the subject of an unsatisfied judgement or lien ? ..................................................................... ...................................29. Are you currently engaged in any other business, either as a prop rietor, partner, officer, director, trustee, employee or otherwise? ... THE FOLLOWING SHOULD BE READ VERY CAREFULLY BY THE APPLICANT 1. I hereby certify that I have read and understand the foregoing st atements and that my responses are true and complete to the best of my knowledge. 2. To induce the Nebraska Securities Bureau, with which I am filing this application to receive and consider it: A. I agree that any decision of the Bureau as to the results of any e xamination(s) that I may be required to pass will be accepted by me as final; B. (1) I understand that I am not authorized to sell, or offer for sale, any securities until I have received my license or registration certificate or any official notification of its effective date; (2) I understand that I am to sell only those securities authorized by my employer. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 C. I agree to abide by the Statute(s), Constitution(s), and Rules as any of the foregoing are amended from time to time of the State of Nebraska and the Nebraska Securities Bureau, with which I am fi ling this application; D. If I shall violate or be charged with the violation or possible vi olation of any Statute, Rule or Constitution of with which I am filing this application, I agree to be subject to and abide by the penal ties of the Statute(s), Constitution(s), or Rules of the Securities Burea
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