Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
Dual Registration
as an Investment Adviser
Representative
and Salesperson
1. Name of each Registered Salesperson of the dealer named below who also has requested to be an Investment Adviser Representative to
the applicant:
2. Dealer Acknowledgement — The undersigned dealer acknowledges that it is aware of the intention of the above-named person(s)
affiliated with the applicant named above to become registered in the State of Illinois as an investment adviser representative, and that the
dealer consents to and is aware of its supervisory responsibilities and potential conflict(s) of interest inherent in such a situation.
Notice to Dealer: This form must be returned to the applicant to be filed with the Application for Registration as an Investment Adviser
Representative.
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 331.1
This form must be completed and filed by the applicant when a person is a registered salesperson of a dealer and applies for
registration as an investment adviser representative under Section 8D of The Illinois Securities Law of 1953.
Name of Salesperson
Name of Salesperson
CRD Number
CRD Number
Name of Salesperson
Name of Salesperson
CRD Number
CRD Number
Name of Investment Adviser Applicant Signature of Officer, Partner or Sole Proprietor
Name and Title (type or print)
Name of Dealer Signature of Officer, Partner or Sole Proprietor
Name and Title (type or print)
