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Securities Agent Simultaneous Licensure Disclosure Application ASIM - Wisconsin
| Securities Agent Simultaneous Licensure Disclosure Application Form. This is a Wisconsin form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES 345 West Washington Ave., 4th Fl. PO Box 1768 Madison, WI 53701-1768 (608) 266-3693 TTY: (608) 266-8818 Internet: www.wdfi.org SECURITIES AGENT SIMULTANEOUS LICENSURE DISCLOSURE APPLICATION Explanatory Note: In order for an agent to simultaneously represent more than one broker-dealer or issuer, Section 551.31(2)(b)(2), Wis. Stats., requires that the Administrator grant approval in writing prior to the agent engaging in such activities. That statue and administrative rule SEC 4.01(8), Wis. Adm. Code, thereunder, requires a written application, which may be a copy of the Form U-4 or in letter form, to be filed with the Administrator in addition to this disclosure form that contains certain required information. Additionally, the rule requires EACH broker-dealer or issuer the agent represents to grant written permission to the agent to represent specified other employers, to list all restrictions they have imposed on the agent's securities activities, and to provide written disclosure of such information to the applicant's customers. Also, the rule requires the agent to sign the disclosure form. Each employing broker-dealer or issuer must provide with this application a copy of the form of written disclosure that will be used to advise clients of the agent's simultaneous licensing status. Approval of the application for simultaneous licensure, if granted, will be evidenced on this form by the Administrator or his designee and a copy supplied to each of the agent's broker-dealer or issuer employers. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. This form is required under Section 551.32(1) Wis. Stats.. Failure to comply within 30 days may result in the denial of a license. Information requested may also be used for secondary purposes. EACH PARTICIPATING BROKER-DEALER/ISSUER MUST COMPLETE AN ASIM(WI) FORM DFI/DOS/ASIM(WI)(R11/03) 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com s.551.31(2)(b)2 Wis. Stats. and 4.01(8), Wis. Adm. Code SECURITIES AGENT SIMULTANEOUS LICENSURE DISCLOSURE APPLICATION A SEPARATE APPLICATION MUST BE COMPLETED BY EACH PARTICIPATING BROKER-DEALER/ISSUER The undersigned ________________________________________ (name of broker-dealer or issuer) acknowledges that _______________________________________ (name of applicant) is/seeks to become (cross-out as applicable) licensed in Wisconsin as a securities agent to represent the undersigned. The undersigned hereby grants permission for the applicant identified above to be simultaneously licensed with the undersigned as well as the following securities broker-dealers or issuers: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The undersigned hereby grants permission for the applicant identified above to simultaneously represent the other securities broker-dealers or issuers listed in the above paragraph, subject to the following restrictions: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The undersigned agrees to provide to each securities customer of the undersigned, written disclosure of the information contained on this form regarding the simultaneous representation by the above identified applicant of more than one broker-dealer or issuer not later than the date of receipt of the confirmation for the first securities transaction for the account of the customer effectuated by the agent after simultaneous licensing of the agent is approved by the Administrator. ________________________________________ Typed Name & Title of Appropriate Signatory ________________________________ Date ________________________________________ Signature of Signatory I acknowledge and verify that the employment information listed above is accurate and agree to the restrictions placed upon my securities activities. ________________________________ Date ________________________________________ Signature of Agent This form is required under Section 551.31(2)(b)2, Wis. Stats. Failure to comply within 30 days may result in fines, penalties or revocation of your license. FOR DIVISION OF SECURITIES OFFICE USE ONLY ____________________________________________________________________________ Simultaneous Licensing Approved: _________________________ Date: _________________ DFI/DOS/ASIM(WI)(R11/03) 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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