Last updated: 8/14/2006
Deferral Request Form-Agent {DFRRLA}
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Description
THE COMMONWEALTH OF MASSACHUSETTS SECRETARY OF THE COMMONWEALTH SECURITIES DIVISION ONE ASHBURTON PLACE BOSTON, MASSACHUSETTS 02108 DEFERRAL REQUEST FORMAGENT ______________________________________________________________ hereby am ends Name of Fir m the application for registration of ____________________________________ _______________ Name of Age nt as an agent of _________________________________________________________ _________ N ame of Firm in Massachusetts and requests a deferral of the thirty-day time period set forth in M.G.L. c.110A, 202 for action by the Securities Division with respect to the application. The undersigned hereby certifies that he/she has the authority to amend the application and to make this request for a deferral on behalf of ____________________________ ______________ N ame of Fir m ____________________ and on behalf of __________________________________ _________ N ame of Age nt and does so pursuant to that authority. _______________________________________ Signature _______________________________________ Print Name and Title _______________________________________ D a te American LegalNet, Inc. www.USCourtForms.com
