Michigan > Secretary Of State > Blue Sky > Securities > Broker-Dealer Agent Registration

Non FINRA Broker Dealer Renewal FIS-0523 - Michigan

Non FINRA Broker Dealer Renewal Form. This is a Michigan form and can be used in Broker-Dealer Agent Registration Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 1/9/2014
Get this form for FREE as a print-only pdf

FIS 0523 (10/11) Office of Financial and Insurance Regulation Non-FINRA Broker-Dealer Renewal Name of Broker-Dealer Address Your Michigan Broker-Dealer number: (This is NOT your CRD number) Contact person name and title Contact person phone number City Check if your address has changed since your last renewal State Tax ID number (FEIN) Zip Code Contact person email address DUE ANNUALLY on or before December 31st of the current year NON- Does Broker-Dealer maintain a Michigan branch office? If yes, please attach a list of Michigan branch office locations. Yes No Agent listing List each agent of this broker-dealer. You may use the space below, or attach a substitute list prepared on your office automation equipment. 1 Name of agent 3 Name of agent Home address (must be street address--no PO Boxes) City State Zip Code Home address (must be street address--no PO Boxes) City State Zip Code Agent Social Security Number Agent Social Security Number 2 Name of agent 4 Name of agent Home address (must be street address--no PO Boxes) City State Zip Code Home address (must be street address--no PO Boxes) City State Zip Code Agent Social Security Number Agent Social Security Number Renewal Fee Calculation--Each Non-FINRA Broker-Dealer firm is subject to a $300 renewal fee PLUS a $65 per agent renewal fee. Complete table below. Quantity 1 Amount Due $300.00 Mail completed form and any attachments with payment to: OFIR-Securities Division 525 W. Allegan, 1st Floor North PO Box 30701 Lansing MI 48909-8201 Broker-Dealer Renewal Agent Renewal (quantity x $65.00) TOTAL--Make check for full amount due payable in US dollars to: State of Michigan C3 Validation code: 8 Certification I swear under penalty of perjury that the information given in and attached to this application is true, complete and correct. I understand that Michigan requires broker-dealer audited financial statements to be submitted within 90 days from the end of the firm's fiscal year, and another unaudited financial statement with net capital computation as of a date six months after the audited statement. Signature of officer, member or owner Date signed Signer's name and title (typed or printed) Authority: PA 551 of 2008. Failure to properly file will result in expiration of your registration. American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. default judgment
  2. certificate of service
  3. child support
  4. answer to complaint
  5. writ
  6. petition
  7. affidavit
  8. probate
  9. order to show cause
  10. motion to dismiss

Bookmark and Share