Michigan > Secretary Of State > Blue Sky > Securities > Investment Adviser Registration
Investment Advisor Supplemental Application Form FIS-0569 - Michigan
| Investment Advisor Supplemental Application Form Form. This is a Michigan form and can be used in Investment Adviser Registration Securities Blue Sky Secretary Of State . |
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FIS 0569 (8/06) Office of Financial and Insurance Services Investment Adviser Supplemental Application Form 1. Applicant Information: Applicant's Name Address (number, street, city, state, zip code) Date: Applicant's IARD Number 2. Has applicant conducted Investment Adviser business with Michigan clients: Yes No If "Yes", submit a written explanation of how applicant is in compliance with the Michigan Uniform Securities Act, 1964 PA 1965, as amended. Provide dates, numbers of clients and consideration received. 3. Is applicant currently registered as an Investment Adviser for Michigan: Address(es) of office(s) in Michigan: Address Address City City State State Zip Code Zip Code Yes No 4. Name, Office Address, CRD# and Social Security # of all persons that will render investment services to Michigan clients. Name Address (number, street, city, state, zip code) Name Address (number, street, city, state, zip code) Name Address (number, street, city, state, zip code) Name Address (number, street, city, state, zip code) CRD No. Social Security No. CRD No. Social Security No. CRD No. Social Security No. CRD No. Social Security No. Continue on page 2 American LegalNet, Inc. www.FormsWorkflow.com FIS 0569 (8/06) Office of Financial and Insurance Services Investment Adviser Supplemental Application Form Page 2 5. Enter names, addresses, and other information requested for all persons associated with, employed by, or who have an ownership interest in applicant, who are currently registered as Securities Agents for Michigan. Provide the name of the brokerage firm where employed and dates of employment. You must describe the nature of the association, employment or ownership interest. IF NO ONE IS REGISTERED AS A SECURITIES AGENT FOR MICHIGAN, PLEASE ANSWER "NONE". If applicant is a sole proprietor and is registered as a Securities Agent for Michigan, please provide complete details. Name Address (Number, Street, City, State, Zip Code) Name of Brokerage Firm where employed: Dates of Employment: From: Name To: CRD No. Describe nature of association, employment, or ownership interest: CRD No. CRD No. Address (Number, Street, City, State, Zip Code) Name of Brokerage Firm where employed: Dates of Employment: From: Name To: CRD No. Describe nature of association, employment, or ownership interest: CRD No. Address (Number, Street, City, State, Zip Code) Name of Brokerage Firm where employed: Dates of Employment: From: Name To: CRD No. Describe nature of association, employment, or ownership interest: CRD No. Address (Number, Street, City, State, Zip Code) Name of Brokerage Firm where employed: Dates of Employment: From: To: Describe nature of association, employment, or ownership interest: CRD No. 6. Check this box if you intend to act as a Finder only as defined in Section 401(i) of Act 265, PA 1964, as amended. Title: Name and Title of person who completed this form: Name: RETURN COMPLETED APPLICATION TO: Office of Financial and Insurance Services Securities Section P.O. Box 30701 Lansing, MI 48909-8201 This form is issued pursuant to Act 265, PA 1964, as amended. It must be completed and filed as part of an application to register as an Investment Adviser. Failure to file will result in denial of your application. American LegalNet, Inc. www.FormsWorkflow.com
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