Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
Additional Information Required
by Section 130.840 of
the Administrative Rules for
Registration as an
Investment Adviser
1. Designated Principal(s) to be Responsible for the Rendering of Investment Advice in Illinois:
A. Applicant understands that each investment adviser registered in the State of Illinois must have at least one examination-qualified
principal who is responsible for the rendering of investment advice and the supervision of each investment adviser representative
servicing Illinois customer accounts. Each designated principal must have passed the qualifying examinations or educational program
designation as set forth in Section 130.842 of the Rules.
B. Name, Social Security Number or CRD Number(s) and qualifying examination(s) and/or education program for each designated principal who
will be responsible for the rendering of investment advice and the supervision of investment adviser representatives in the State of Illinois:
C. Applicant undertakes to amend this list and file the amendment with the Illinois Securities Department no later than 10 business days
after any change of any designated principal.
2. Affidavit of Prior Investment Adviser Activities in Illinois — Applicant hereby applies for registration as an investment adviser to engage
in rendering investment advice in the State of Illinois. Applicant hereby certifies that (check A or B):
❏ A. 1. Neither applicant nor any of his/her representatives has rendered any investment advice for a fee or entered into any
agreement to render investment advice for a fee to any Illinois residents; and
2. Neither applicant nor any of his/her representatives will engage in the business of rendering investment advice for a fee to
Illinois residents until said firm is registered to do so with the Illinois Securities Department.
❏ B. Applicant has rendered investment advice for a fee to Illinois residents. All information relating to said advice is attached,
including the exemption or exclusion 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.
3. Investment Adviser Representations Under the Illinois Securities Law of 1953 — Applicant makes the following representations as a
condition to registration as an investment adviser under the provisions of Section 8.D of the Illinois Securities Law of 1953 and its relevant
Administrative Rules thereunder:
A. Applicant will not charge or receive compensation in connection with the rendering of investment advice unless such compensation
is fair and reasonable, is determined on an equitable basis and adequately disclosed in writing to each Illinois advisory client.
Negotiable fees will not be based upon capital gains or performance unless in conformance with the provisions of Rule 205-3 under
the Investment Advisers Act of 1940; and
B. Applicant, when selecting the services of a dealer to effectuate securities transactions for Illinois advisory clients, will utilize dealers
registered in the State of Illinois unless such transactions are otherwise exempt pursuant to Section 4 of the Act; and
C. Applicant will ensure that each designated principal and each investment adviser representative who offers for sale or sells securities
in the State of Illinois will be registered as a salesperson under Section 8.C of the Act; and
D. Applicant will provide each Illinois advisory client and prospective advisory client with a written disclosure statement (brochure) as
required by Section 130.846 of the Rules under the Act and Rule 204-32 under the Investment Advisers Act of 1940. Adverse financial
and disciplinary information will be disclosed in accordance with the provisions of Section 130.847 of the Rules under the Act.
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.
♻ Printed on recycled paper. Printed by authority of the State of Illinois. November 2015 — 100 — SEC 321.3
Name of Designated Principal CRD Number
CRD Number
CRD Number
Qualifying Exams/Designations
Qualifying Exams/Designations
Qualifying Exams/Designations
Name of Designated Principal
Name of Designated Principal
Name of Applicant:
Signature of Officer, Partner, Sole Proprietor:
Name and Title (type or print), Date:
