3. Request for Waiver of Records to be Maintained in Illinois — Applicant will not maintain its principal office in the State of Illinois and
requests a waiver of Section 130.825 of the Rules under the Illinois Securities Law of 1953.
A. Applicant affirms that the records pertaining to the offer or sale of securities to or purchased from Illinois residents will be maintained
separately and in such a manner that they can be made available upon request by the Illinois Securities Department within 72 hours.
Name, Address and Telephone Number where Illinois records will be maintained:
B. In the event such records are maintained in a location outside the principal office of the dealer, the relationship to the dealer is:
C. Applicant understands that if it is a Corporation and opens a branch office in the State of Illinois, as defined in Section 130.280 of the
Rules, the applicant must file as a Foreign Corporation with the Department of Business Services, Office of the Secretary of State.
4. Affidavit of No Sale of Securities in Illinois — Applicant hereby applies for registration as a dealer to engage in the sale of securities in
the State of Illinois. Applicant hereby certifies that (check A or B):
o A. 1. Neither applicant nor any of its representatives has sold or entered into any agreement to sell any securities to any Illinois
residents; and
2. Neither applicant nor any of its representatives will engage in the business of offering or selling securities to Illinois residents
until said firm is registered to do so with the Illinois Securities Department.
o B. Applicant has engaged in the offer or sale of securities to Illinois residents. All information relating to said sales is attached,
including the exemption under which Illinois residents' accounts have been or are being serviced, if applicable.
Applicant acknowledges the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Illinois Securities
Department may result in enforcement action.
5. Salesperson(s) to be Registered Under Section 8.C:
A. Applicant understands that each registered dealer in the State of Illinois must have at least one salesperson registered under Section
8.C of The Illinois Securities Law of 1953, except a registered dealer who effects trades solely as a clearing dealer on behalf of other
dealers. Each salesperson to be registered in Illinois must have passed the qualifying examinations as set forth in Section 130.832 of
the Rules.
B. Applicant understands that each designated principal who offers for sale or sells securities in the State of Illinois must be registered
as a salesperson under Section 8.C of the Act.
C. Applicant will effect trades solely as a clearing dealer on behalf of other dealers in the State of Illinois:
o Yes
o No — If no, Complete item D.
D. Name and CRD Number(s) of at least one or more person(s) to be registered as salesperson(s) in the State of Illinois for which Form
U-4 and the filing fee are being submitted to the Financial Industry Regulatory Authority (FINRA) through the CRD System. The dealer
registration will not be granted until the Illinois Securities Department has verified that Form U-4 has been filed and the filing fee paid
to the FINRA.
E. Applicant undertakes to maintain the registration of salesperson(s) under the Act, unless a clearing dealer, as long as applicant is
registered as a dealer in the State of Illinois. Applicant understands that failure to maintain a registered salesperson may result in
administrative action to suspend or revoke the dealer registration.
Name
Telephone Number
Address
City, State, ZIP
Name of Salesperson CRD Number
CRD Number
CRD Number
CRD Number
Name of Salesperson
Name of Salesperson
Name of Salesperson
Name and Title of Applicant (type or print) Signature of Officer, Partner, Sole Proprietor Date
