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Wisconsin Agent For Issuer U4 Supplemental Information U-4S - Wisconsin
| Wisconsin Agent For Issuer U4 Supplemental Information Form. This is a Wisconsin form and can be used in Securities Blue Sky Secretary Of State . |
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ยง551.402(1) & (4), Wis. Stats. and 4.01(1) & (4)(c), Wis. Adm. Code STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES 345 West Washington Ave., 4 Fl. PO Box 1768 Madison, WI 53701-1768 (608) 266-2139 TTY: (608) 266-8818 Internet: www.wdfi.org th WISCONSIN AGENT FOR ISSUER U4 SUPPLEMENTAL INFORMATION 1. Name of Issuer: ___________________________________________________________________ 2. Name of Offering:__________________________________________________________________ 3. Full name, residence and Social Security number of agent applicant: ___________________________________________________________________________________ (Last) (Street Address or Route Number) (First) (Middle) ___________________________________________________________________________________ _____________________________________________________ ____________________________ (City) (State) (Zip) (Social Security Number) 4. Has applicant previously been registered in Wisconsin? ______________Yes _____________ No If "yes", provide name of broker-dealer or issuer for whom registrationd: ________________________________________ 5. Applicant's Wisconsin securities activities will consist of: _____Solicitation only, no sales _____Agent of Issuer sales for: _______Registered Securities _______Exempt Offering (S-63 Exam Results & Proof of Applicable FINRA Exam Attached) QUALIFICATION EXAMINATIONS: Each AGENT FOR ISSUER registration applicant must have passed the Uniform Securities Agent State Law Examination (S63) and the FINRA Representative's Examination applicable to the type of securities business the applicant will transact. UNDERTAKING: Each application must be accompanied by an Undertaking outlining the training and supervision that will be provided by the issuer. FEES: Each applicant must include the $80 filing fee prescribed by sec. 551.614(2), Wis. Stats. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. This form is required under Section 551.406(1) Wis. Stats. Failure to comply within 30 days may result in the denial of a registration. Personally identifiable information collected on this form may be matched against tax information, outstanding child and family support data and information from law enforcement agencies. Other information requested may also be used for secondary purposes. FOR SECURITIES OFFICE USE ONLY Filing Fee: _______________ Receipt Number: __________ DFI/DOS/U4S(WI)(R4/12) Registration Number: __________ Registration Date: ____________ Limitations: ______________ American LegalNet, Inc. www.FormsWorkFlow.com
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