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State Retirement System Investment Officer SRSIO - Ohio
| State Retirement System Investment Officer Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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$ (For Division Use Only STATE OF OHIO Department of Commerce Division of Securities nd 77 South High Street, 22 Floor Columbus, Ohio 43215-6131 (614) 644-7381 FORM SRSIO State Retirement System Investment Officer PART I: State Retirement System 1. Full name: 2. Address of Principal Place of Business: 3. Telephone No.: 4. Facsimile No.: PART II: Applicant 1. Full name: 2. Home Address 3. Telephone No.: 4. Facsimile No.: 5. Social Security No.: 6. Fingerprint Card: A fingerprint card properly completed by the applican t: is included with this Form SRSIO will be filed separately PART III: Qualifications 1. Indicate the qualification of the applicant: A. The Division shall consider an applicant for licensing to have met this requirement if the applicant was employed by a state retirement system o n, or before, September 14, 2004 and the applicant has satisfied one of the following education and experience requirements or achieved one of the following designations: A bachelors degree from an accredited college or university and five years of relevant investment experience; A masters degree from an accredited college or university; or A doctorate degree from an accredited college or university. COM 4751 (5/05) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Earned, and is in good standing with the organization that issued, any one of the following credentials: "Certified Financial Planner" awarded by the "Certified Financial Planner Board of Standards, Inc."; Chartered financial analyst designation; Chartered financial consultant; Chartered investment counselor; or Certified public accountant with a personal financial specialist designation. B. For applicants employed by a state retirement system on, or after, Septe mber 15, the applicant must have either: Achieved a passing score on one of the following examinations: The series 63 examination administered by the National Association of Securities Dealers, Inc. The series 65 examination administered by the National Association of Securities Dealers, Inc. The series 66 examination administered by the National Association of Securities Dealers, Inc. The level one examination administered by the CFA Institute; or Earned, and is in good standing with the organization that issued, any one of the following credentials: "Certified Financial Planner" awarded by the "Certified Financial Planner Board of Standards, Inc."; Chartered financial analyst designation; Chartered financial consultant; Chartered investment counselor; or Certified public accountant with a personal financial specialist designation. PART IV: Disclosure 1. Have you ever found guilty of any felony? Have you ever been found guil ty of any misdemeanor involving theft, deception or moral turpitude? Yes No (If yes, attach a sheet reporting the charge and the date, place and fi nal disposition of the charge.) 2. Have you ever been refused a license or registration, or been censured o r disciplined by any State or Federal Agency, Stock Exchange, or NASD for any activity which would constitute a lack of "good business repute" as defi ned in O.A.C. 1301:6-3-19(D)? Yes No (If yes, attach a sheet reporting the date, place and final disposition of the matter.)3. Periods during which the applicant has previously been licensed by the O hio Division of Securities. (If none, so state.) COM 4751 (5/05) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 34. Employment Record: Complete information must be given covering the ten year period immediately preceding the date of this application. Also include intervals of unemployment. To avoid delays in processing, furnish correct names and addresses of all employers. State if former employer is out of business . For additional space please attach a separate sheet. Period of Employment Employers Names & Address Nature of Employment From: Name To: Address From: Name To: Address From: Name To: Address From: Name To: Address PART V: Signatures 1. Applicant The undersigned represents that the foregoing information is true and ac curate to the best of the applicants knowledge as of the date hereof, and agre es that this form constitutes a written statement for purposes of R.C. 1707.44(B). ________________________________________ Applicants signature named in Part II ________________________________________ Date 2. Retirement System The undersigned represents that he/she is duly authorized to do so, the foregoing applicant is employed or has been offered employment, and represents tha t the information provided in foregoing Parts I, II and III is true and accura te to the best of the retirement systems knowledge as of the date hereof, and agrees t hat this form constitutes a written statement for purposes of R.C. 1707.44(B). _____________________________________ State Retirement System named in Part I By: __________________________________ Signature (Cannot be the same person as Applicant named in Part II) Print name and title Date COM 4751 (5/05) American LegalNet, Inc. www.USCourtForms.com
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