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Form X-17A-19 Report Of Change In Memberhip Status (SEC1414) X-17A-19 - Official Federal Forms
| Form X-17A-19 Report Of Change In Memberhip Status (SEC1414) Form. This is a national form and can be used in Securities And Exchange Commission . |
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 OMB APPROVAL OMB Number: 3235-0133 Expires: November 30, 2014 Estimated average burden hours per response. . . . . 0.25 FORM X-17A-19 INFORMATION REQUIRED OF NATIONAL SECURITIES EXCHANGES AND REGISTERED NATIONAL SECURITIES ASSOCIATIONS PURSUANT TO SECTIONS 17 AND 19 OF THE SECURITIES EXCHANGE ACT OF 1934 AND RULE 17a-19 THEREUNDER REPORT OF CHANGE IN MEMBERSHIP STATUS 1. Identify the self-regulatory organization filing this report. AMEX BSE CBOE CSE CHX ISE NASD NYSE PCX PHLX 2. The change in membership with the reporting self-regulatory organization is: (a) (d) New Membership Reinstatement from Suspension (b) (e) Termination of Membership Change of Address (c) (f) Suspension of Membership Other Change in Membership Status If (b), (c), (d) or (f) give a brief description of the circumstances ___________________________________________________ _______________________________________________________________________________________________________ 3. Provide the following information concerning the subject. Present Status: (a) thru (d) (a) Name _____________________________________ (b) Corporation LLC Partnership Sole Proprietor To be changed to (a) thru (d) (a) Name ________________________________________ (b) Corporation LLC Partnership Sole Proprietor - Other ___________________ - Other ___________________ (c) SEC File No. _______________________________ (d) Principal Place of Business: _____________________________________________ (Number and Street) (c) SEC File No. _______________________________ (d) Principal Place of Business: _____________________________________________ (Number and Street) _____________________________________________ (City) (State) (Zip Code) _____________________________________________ (City) (State) (Zip Code) 4. The subject is also a member of the: AMEX BSE CBOE CSE CHX ISE NASD NYSE PCX PHLX 5. The examining authority and SIPC collection agent prior to this change in membership status is: AMEX BSE CBOE CSE CHX ISE NASD NYSE PCX PHLX 6. Name of person completing report _______________________________ Title __________________________________ Effective Date Telephone No ______________________ Signature _________________________________ of Change ____________ (ADVISE BROKER-DEALER OF ITS OBLIGATION TO AMEND ITS FORM BD OR FILE FORM BDW) RESERVED FOR SEC ACTION Examining Authority Not Changed Examining Authority Changed From _______________ to _______________ Date __________________________ Signature __________________________________________________________ INSTRUCTIONS ON BACK SEC 1414 (07-01) Persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INSTRUCTIONS FORM X-17A-19 1. This Form shall be completed and filed within 5 business days of the occurrence of one or more of the changes in membership status listed in Item 2 and/or 3 on this Form or promptly upon learning that such changes will occur. If the information first becomes available after the change in membership status has occurred, the Form shall be completed and filed promptly. 2. Original - Mail to: U.S. Securities and Exchange Commission Division of Market Regulation 100 F Street, N.E. Washington, D.C. 20549-6628 Securities Investor Protection Corporation 805 15th Street, N.W., Suite 800 Washington, D.C. 20005 Retain for your files. Copy No. 1 - Mail to: Copy No. 2: 3. The original filed with the Securities and Exchange Commission and the copy filed with the Securities Investor Protection Corporation shall be executed with a manual signature by a duly authorized official of the national securities exchange or registered securities association (self-regulatory organization). 4. If the space provided in the Form for an answer to any Item is insufficient, the answer may be printed or typed on a separate insert page or pages which shall be incorporated into the statement by reference thereto in the space provided for the Item. 5. If any Item of the Form is inapplicable, a statement to that effect shall be made following the Item. 6. Change of member's address is required to be reported only by the examining authority. 7. Copies of this Form may be obtained from the main office of the Securities and Exchange Commission in Washington, D.C. 8. The Securities and Exchange Commission will use a copy of this Form to notify Securities Investor Protection Corporation and the affected self-regulatory organizations of any action that is taken. (ADVISE BROKER-DEALER OF ITS OBLIGATION TO AMEND ITS FORM BD OR FILE FORM BDW) American LegalNet, Inc. www.FormsWorkFlow.com
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