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Information Request Form For (CRD) NJBOS-4 - New Jersey

Information Request Form For (CRD) Form. This is a New Jersey form and can be used in Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 2/25/2009
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NEW JERSEY BUREAU OF SECURITIES th 153 Halsey Street, 6 Floor Post Office Box 47029 Newark, NJ 07101 Telephone (973) 504-3658 Fax (973) 504-3624 E-mail: askbureauofsecurities@lps.state.nj.us INFORMATION REQUEST FORM FOR CENTRAL REGISTRATION DEPOSITORY AND/OR INVESTMENT ADVISER REGISTRATION DEPOSITORY INFORMATION INSTRUCTIONS: This form should be completed to request information available from the Central Registration Depository (CRD) and/or the Investment Adviser Registration Depository (IARD) pertaining to agents, broker-dealers, and/or investment advisers. Both pages of this form should be read and completed before signing and submitting. 1. Requested by: Name: ______________________________________________________________ _____ Address: ___________________________________________________________ ______ City: _________________________________ State: __________ ZIP Code: __________ Telephone: ____________________________ Fax: ______________________ ________ E-mail address: ____________________________________________________ ________ 2. Name of agent: ______________________________________________________ ______ Firm affiliation: ___________________________________________________________ Identifying information: CRD/IARD #:__________________ SS#:___________________ Information requested: _____________________________________________ _________ 3. Name of broker-dealer: ______________________________________________ _______ Information requested: _____________________________________________ _________ 4. Name of investment adviser: _________________________________________ ________ Information requested: _____________________________________________ _________ 5. Reason for request: _________________________________________________ ________ 6. The Bureau of Securities reserves the right to charge for copies of documents in excess of 20 pages at the rate of $.25 per page. 7. The Bureau of Securities cannot guarantee the accuracy or completeness of the information furnished in reply to your request. Undisclosed information may exist in other jurisdictions or with self-regulatory bodies. The Bureau of Securities is not responsible for information obtained from other sources. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 28. The Bureau of Securities has not passed upon the merits or qualifications of, or recommended or given approval to, any person, security, or transaction. The fact that a person or security has been registered does not constitute a finding by the Bureau of Securities that any document filed is true, complete, or not misleading. 9. If you wish to request any additional documentation, you may submit a request pursuant to the Right to Know Law, N.J.S.A. sec. 47:1A-1 et seq. (OPRA). For information concerning an OPRA request for Bureau of Securities records, you must contact Consumer Affairs at (973) 424-8111 or www.nj.gov/lps/opra . I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT WITH REGARD TO THE FURNIS HING BY THE BUREAU OF SECURITIES OF THE INFORMATION REQUESTED. PLEASE SEND ME THE DOCUMENTS AND/OR INFORMATION REQUESTED ABOVE. _____________________________________ _________________________ Signature Date Form NJBOS-4 4/2005 American LegalNet, Inc. www.USCourtForms.com
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