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Broker-Dealer Questionnaire And Affidavit Prior Sales BDQAPS - Ohio
| Broker-Dealer Questionnaire And Affidavit Prior Sales Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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BROKER-DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES Date: __________________ Full Name of Broker-Dealer: ____________________________________________ _____________________ Firm CRD No.: ________________ The undersigned Principal certifies as follows: I have conducted a tho rough review into the activities of the Broker-Dealer listed above, and, to the best of my knowledge with in the past 36 months, the Broker-Dealer has not effected non-exempt transactions in the State of O hio. If any transaction were made in reliance upon an exemption, I have attac hed a list of those transactions. As to those transactions, I have identified the exemption upon which the Broker-Dealer relied and an explanation. For those transactions that occurred within the past 36 months that were effected without the benefit of an exemption, I am providing the following information: The accountholders name, address and telephone number; Name of the security; Date and amount of the trade, including the commission paid to the Broke r-Dealer and to the Agent; and The Agent who effected the transaction. I am aware that the State of Ohio may verify this information with my cl earing firm. I further certify that the Broker-Dealer listed above will refrain from transacting business as a Broker- Dealer in Ohio until registration is completed. I acknowledge that if my response to any of the above if false or if the Broker-Dealer transacts business during the period prior to registration, the Broker-Dealer and I are sub ject to sanctions pursuant to the laws of Ohio. Name of Principal (Please print) Signature of Principal Subscribed and sworn before me this day of , 2003. County of , State of .My commission expires . Notary Public American LegalNet, Inc. www.USCourtForms.com
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