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Information To Be Furnished By Promoters Directors Officers And Partners Of Issuers Or Investment Advisers R4 - Puerto Rico
| Information To Be Furnished By Promoters Directors Officers And Partners Of Issuers Or Investment Advisers Form. This is a Puerto Rico form and can be used in Securities Blue Sky Commissioner Of Financial Institutions . |
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FORM R-4 05/10 COMMONWEALTH OF PUERTO RICO COMMISSIONER OF FINANCIAL INSTITUTIONS Centro Europa Building, Suite 600, 1492 Ponce de León Avenue, San Juan, P.R. 00907-4127 Tel. (787) 723-8403 Fax (787) 724-2604 INFORMATION TO BE FURNISHED BY PROMOTERS, DIRECTORS, OFFICERS AND PARTNERS OF, ISSUERS OR INVESTMENT ADVISERS Instruction: This form must be completed and signed by all promoters of an investment adviser and by such of its directors, officers and/or partners whose services are to be performed in Puerto Rico; and by all promoters, directors, officers and/or partners of an issuer where such issuer is to offer its securities for sale in Puerto Rico and the issuer has not been organized and in operation for at least two (2) years prior to the date of filing of the issuer's registration statement. The executed forms are to be filed as exhibits to the registration statement of the issuer or investment adviser. 1._________________________________________________________________________ Issuer or Investment Adviser with which principal is associated 2. _________________________________________ Full name of the principal executing this form _________________________________________ Place and Date of Birth ____________________________ Social Security No. _____________________________ Citizenship __________________________________________________________________________ Business Address 3. State whether you are an officer, director, partner, promoter or employee of the above named dealer, issuer or investment adviser: ____________________________________________________________________________ 4. Furnish the following information: (a) Record of occupation for ten years immediately preceding date of this form. (Give full details. Attach an additional sheet if necessary in order to provide particulars.) Type of Date of Employment Business Position Address Employer ____________________________________________________________________________ ____________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Form R-4 05/10 Page 2 (b) States in which you have been licensed or registered within the last ten (10) years to engage in the securities business. ______________________________________________________________________ Have you taken the examination given by the National Association of Securities Dealers or The New York Stock Exchange?_______________ If, so, state wheather you passed, which examination and give date. ____________________________________________________________________ Have you been engaged in the securities business on a full time basis for the five (5) years immediately preceding the filing of this form? ______________________________ (c) (d) 5. Do you own securities in this organization? ___________________________________ (a) Kind, amount and percentage of ownership of each class _____________________ ______________________________________________________________________ (b) How were they paid for? (If other than cash, explain fully.) ___________________________________________________________________ (c) Is payment completed? (If not, explain) _______________________________ ___________________________________________________________________ 6. Have you any agreement, written or otherwise, relating to the acquisition of any additional interest? (If "yes" give full particulars on separate sheet, marked Exhibit 1). ___________________________________________________________________________ ___________________________________________________________________________ 7. State in full your arrangements with this organization regarding compensation, salary, commission, profit-sharing, bonus, and any other payments made for any purpose within the last three (3) years whether directly to you or to any person in whom you have a financial interest. (Attach a separate sheet if necessary, marked Exhibit 2 ).______________________ ___________________________________________________________________________ 8. (a) What amount of your time do you devote to this organization's business or affairs? ____________________________________ (b) Will you be engaged in such activities on a full-time or a part-time basis?_____________ American LegalNet, Inc. www.FormsWorkFlow.com Form R-4 05/10 Page 3 9. Have you ever: Yes (a) Been an officer, director or promoter in a company which has become insolvent? (b) Been convicted of any fraudulent acts in any transaction of any kind or character? (c) Been convicted of any misdemeanor involving a security or any aspect of the securities business, or of any felony? (d) Been declared bankrupt, or made an assignment for the benefit of creditors? (e) Been permanently or temporarily enjoined from engaging in or continuing any conduct or practice involving any aspect of the securities business? No Instruction: If the answer to any part of question 9 is in the affirmative, attach a separate sheet providing full particular. If during the period of your association with the issuer or investment adviser an event occurs which would cause a current affirmative answer to any part of item 9, notify the Securities Regulation Division in writing as to the facts relating to such event. 10. Have you or applicant company ever been the subject of any order entered by any state regulatory or administrative agency, department or office or the Securities & Exchange Commission, or any association of securities dealers, or securities exchange? ________________________________________________________________________ ________________________________________________________________________ Instruction: If any part of question l0 is answered affirmatively, attach a separate sheet and provide full particulars. American LegalNet, Inc. www.FormsWorkFlow.com Form R-4 05/10 Page 4 EXECUTION I, ________________________________________________ do solemnly swear that the foregoing answers and statements, together with those in all Exhibits attached hereto, have been knowingly made by me and that the same are true and correct, and that I have not omitted to state any material fact bearing upon such matters. Given under my hand this __________day of ___________ ______ (year) ____________________________ Signature of Principal Affidavit number ___________ Subscribed and sworn before me by __________________________ of legal age, ________________________________________, (married or single) and resident of __________________ person
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