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Agents To Be Renewed S.D.4.A. - Virginia
| Agents To Be Renewed Form. This is a Virginia form and can be used in Securities And Franchising Blue Sky Secretary Of State . |
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S.D.4.A. EXHIBIT I (Revised 1974) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING AGENTS TO BE RENEWED (A separate sheet may be attached if necessary) NAME ADDRESS In order to assist in determining the character and reputation of the ab ove listed individuals, please check below whether or not they have ever been involved in any of the following: YES NO Convicted of a felony or misdemeanor involving dishonesty. ( ) ( ) Sued for fraud, deceit or breach of trust. ( ) ( ) Adjudicated as bankrupt. ( ) ( ) Any unsatisfied judgments. ( ) ( ) Denied a license to sell securities. ( ) ( ) A securities license suspended or revoked. ( ) ( ) Ever been permanently enjoined by any securities ( ) ( ) or commodities regulatory agency. If the broker-dealer is unable to answer any of the above with a (NO), specific information must be given concerning the agent involved. CERTIFICATE The broker-dealer named in the foregoing renewal application certifies t hat the information supplied is true and correct to the best of its knowledge and promises t o notify the Commission promptly with respect to any change in information heretofore given. Ea ch individual as listed is associated with this firm as an agent and full responsibility is accepte d while he is acting in this capacity. _____________________________________________________ Broker-Dealer Date _____________________________________________________ By (Signature) Title American LegalNet, Inc. www.USCourtForms.com
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