Investment Advisor-Broker Dealer Dual Registration Consent

COMMONWEALTH OF PUERTO RICO COMMISSIONER OF FINANCIAL INSTITUTIONS INVESTMENT ADVISER / BROKER - DEALER DUAL REGISTRATION CONSENT I, _________________________, a registered representative of __________________________, request written consent to act as a registered investment adviser. I am currently I am in the process of registration Such registration is in the name of _________________________________________________________ Corporation, Partnership or Sole or Proprietor I understand that I must submit the following documents to ______________________________________ Broker-dealer - Copy of current Form ADV Copy of most recently filed Form ADV-s (renewal form) Copy of Advisory Agreement, Disclosure Statement and other related documents Sales Brochures, If any Proof of SEC and State registrations (copy of approval letter of certificate) ___________________ Date _______ ____________________________ Signature ____________________________________ Registered Representative (print name) ________________________________________does hereby consent to the dual registration of the above Broker-dealer signed registered representative as both an investment adviser and a registered representative. _____________________________ Date ________________________________________ Broker-dealer ________________________________________ _________________________________________ Print name and title Rev. 03-13 American LegalNet, Inc. www.FormsWorkFlow.com