Fillable Form U4: Securities Industry Uniform Application Registration or (California)

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Form U4: Securities Industry Uniform Application Registration or (California)

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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Form U4
Uniform Application
for
Securities Industry
Registration or Transfer
GENERAL INSTRUCTIONS
The Form U4 is the Uniform Application for Securities Industry
Registration or Transfer. Representatives of broker-dealers,
investment advisers, or issuers of securities must use this form
to become registered in the appropriate jurisdictions and/or
SROs. These instructions apply to the filing of Form U4
electronically with the Central Registration Depository ("CRD
®
")
or the Investment Adviser Registration Depository ("IARD
SM
").
Filers submitting paper filings should read the Special
Instructions for Paper Filers in conjunction with the other
instructions to the form. In addition, paper filers should contact
the appropriate jurisdiction and/or SRO for specific filing
instructions or requirements.
Filers must answer all questions and submit all requested
information, unless otherwise directed in the Specific
Instructions.
Use the Disclosure Reporting Page(s) (DRPs U4) to provide
details to the "Yes" answers on Section 14 (DISCLOSURE
QUESTIONS). Upon request, you may be required to provide
documents to clarify or support responses to the form.
A
n individual is under a continuing obligation to amend and
update information required by Form U4 as changes occur.
A
mendments must be filed electronically (unless the filer is an
approved paper filer) by updating the appropriate section of
Form U4. A copy, with original signatures, of the initial Form U4
and amendments to DRPs U4 must be retained by the filing
firm and must be made available for inspection upon regulatory
request. Social Security Numbers are collected for regulatory
purposes and may be publicly disclosed by certain jurisdictions.
The Sections of the Form U4 are as follows:
1. GENERAL INFORMATION
2. FINGERPRINT INFORMATION
3. REGISTRATION WITH UNAFFILIATED FIRMS
4. SRO REGISTRATIONS
5. JURISDICTION REGISTRATIONS
6. REGISTRATION REQUESTS WITH AFFILIATED
FIRMS
7. EXAMINATION REQUESTS
8. PROFESSIONAL DESIGNATIONS
9. IDENTIFYING INFORMATION/NAME CHANGE
10. OTHER NAMES
11. RESIDENTIAL HISTORY
12. EMPLOYMENT HISTORY
13. OTHER BUSINESS
14. DISCLOSURE QUESTIONS
CRIMINAL DISCLOSURE (Questions 14A, 14B)
REGULATORY ACTION DISCLOSURE (Questions 14C,
14D, 14E, 14F, 14G)
CIVIL JUDICIAL DISCLOSURE (Question 14H)
CUSTOMER COMPLAINT/ARBITRATION/CIVIL
LITIGATION DISCLOSURE (Question 14I)
TERMINATION DISCLOSURE (Question 14J)
FINANCIAL DISCLOSURE (Questions 14K, 14L, 14M)
15. SIGNATURE
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGMENT
AND CONSENT
15B. FIRM/APPROPRIATE SIGNATORY
REPRESENTATIONS
15C. TEMPORARY REGISTRATION
ACKNOWLEDGMENT
15D. AMENDMENT INDIVIDUAL/APPLICANT'S
ACKNOWLEDGMENT AND CONSENT
15E. FIRM/APPROPRIATE SIGNATORY AMENDMENT
REPRESENTATIONS
15F. FIRM/APPROPRIATE SIGNATORY
CONCURRENCE
DISCLOSURE REPORTING PAGES (DRPs U4)
CRIMINAL DRP
REGULATORY ACTION DRP
INVESTIGATION DRP
CIVIL JUDICIAL DRP
CUSTOMER COMPLAINT/ARBITRATION/CIVIL
LITIGATION DRP
TERMINATION DRP
BANKRUPTCY/SIPC/COMPROMISE WITH CREDITORS
DRP
BOND DRP
JUDGMENT/LIEN DRP
Contact the appropriate SRO or jurisdiction, if you hav
e
questions about the Form U4.
EXPLANATION OF TERMS
The following definitions apply to terms that are italicize
d
in Form U4.
AFFILIATED means under common ownership or control.
AFFILIATED FIRM means a broker-dealer under commo
n
ownership or control with the filing firm.
APPLICANT means the individual for whom the Form U4 i
s
being filed. The term applicant may be used interchangeabl
y
with the term “individual.” The instructions also refer to th
e
individual applicant as “you” in various places becaus
individuals independently may complete all or portions of th
e
Form U4 before it is filed by a firm on the individual’s behalf.
For purposes of Form U4, an applicant is not a firm.
APPROPRIATE SIGNATORY means the individual the fir
m
authorizes to execute the applicant's Form U4 on the filin
g
firm's behalf. The appropriate signatory must meet the criteri
a
established, if any, by the appropriate SRO or jurisdiction.
CHARGED means being accused of a crime in a forma
l
complaint, information, or indictment (or equivalent forma
l
charge).
CONTROL means the power to direct or cause the direction of
the management or policies of a company, whether through
ownership of securities, by contract, or otherwise. Any
individual or firm that is a director, partner, or officer exercising
executive responsibility (or having similar status or functions) o
r
that directly or indirectly has the right to vote 25 percent or
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
more of the voting securities or is entitled to 25 percent or more
of the profits is presumed to control that company.
DESIGNATED ENTITY means the entity designated as the
filing depository by the U.S. Securities and Exchange
Commission pursuant to the Investment Advisers Act of 1940.
ENJOINED includes being subject to a mandatory injunction,
prohibitory injunction, preliminary injunction or a temporary
restraining order.
FEDERAL BANKING AGENCY shall include any Federal
banking agency as defined in Section 3 of the Federal Deposit
Insurance Act (12 U.S.C. 1813(q)).
FELONY, for jurisdictions that do not differentiate between a
felony or misdemeanor, is an offense punishable by a sentence
of at least one year imprisonment and/or a fine of at least
$1,000. The term also includes a general court martial.
FILING FIRM means the firm named in Section 1 (GENERAL
INFORMATION) on the Form U4.
FINAL ORDER, for purposes of Question 14D(2), means a
written directive or declaratory statement issued by an
appropriate federal or state agency (as identified in Question
14D(2)) pursuant to applicable statutory authority and
procedures, that constitutes a final disposition or action by that
federal or state agency.
FIRM means a broker-dealer, investment adviser, or issuer, as
appropriate.
FIRM CRD NUMBER is a unique number assigned to each firm
listed in the CRD or IARD systems.
FOREIGN FINANCIAL REGULATORY AUTHORITY includes
a foreign securities authority; any other governmental body or
foreign equivalent of a self-regulatory organization empowered
by a foreign government to administer or enforce its laws
relating to the regulation of investment-related activities; or a
membership organization, a function of which is to regulate the
participation of its members in investment-related activities
listed above.
FOUND includes adverse final actions, including consent
decrees in which the respondent has neither admitted nor
denied the findings, but does not include agreements,
deficiency letters, examination reports, memoranda of
understanding, letters of caution, admonishments, and similar
informal resolutions of matters.
INDIVIDUAL CRD NUMBER is a unique number assigned to
each individual listed in the CRD or IARD system.
INVESTIGATION includes: (a) grand jury investigations; (b)
U.S.
Securities and Exchange Commission investigations after
the “Wells” notice has been given; (c) NASD investigations
after the “Wells” notice has been given or after a person
associated with a member, as defined in the NASD By-Laws,
has been advised by the staff that it intends to recommend
formal disciplinary action; (d) formal investigations by other
SROs
;
or
(
e
)
actions or
p
rocedures desi
g
nated as
investigations by jurisdictions. The term investigation does no
t
include subpoenas, preliminary or routine regulatory inquirie
s
or requests for information, deficiency letters, “blue sheet
”
requests or other trading questionnaires, or examinations.
INVESTMENT-RELATED pertains to securities, commodities,
banking, insurance, or real estate (including, but not limited to,
acting as or being associated with a broker-dealer, issuer
,
investment company, investment adviser, futures sponsor
,
bank, or savings association).
INVOLVED means doing an act or aiding, abetting, counseling,
commanding, inducing, conspiring with or failing reasonably t
o
supervise another in doing an act.
JURISDICTION means a state, the District of Columbia, th
e
Commonwealth of Puerto Rico, or any subdivision or regulator
y
body thereof.
MINOR RULE VIOLATION is a violation of a self-regulator
y
organization rule that has been designated as “minor” pursuan
t
to a plan approved by the U.S. Securities and Exchang
e
Commission. A rule violation may be designated as “minor
”
under a plan if the sanction imposed consists of a fine o
f
$2,500.00 or less, and if the sanctioned person does no
t
contest the fine. Check with the appropriate self-regulator
y
organization to determine if a particular rule violation has bee
n
designated as “minor” for these purposes.
MISDEMEANOR, for jurisdictions that do not differentiat
e
between a felony or misdemeanor, is an offense punishable b
y
a sentence of less than one year imprisonment and/or a fine o
f
less than $1,000. The term also includes a special cour
t
martial.
ORDER means a written directive issued pursuant to statutor
y
authority and procedures, including orders of denial,
suspension, or revocation; does not include specia
l
stipulations, undertakings or agreements relating to payments
,
limitations on activity or other restrictions unless they ar
e
included in an order.
PROCEEDING includes a formal administrative or civil actio
n
initiated by a governmental agency, self-regulatory organizatio
n
or foreign financial regulatory authority, a felony crimina
l
indictment or information (or equivalent formal charge), or
a
misdemeanor criminal information (or equivalent forma
l
charge), but does not include an arrest or similar charg
e
effected in the absence of a formal criminal indictment o
r
information (or equivalent formal charge). NOTE: Investment
-
related civil litigation, other than that specified above, i
s
reportable under Question 14H on Form U4. An investigation i
s
reportable under Question 14G on Form U4.
RESIGN or RESIGNED relates to separation from employmen
t
with any employer, is not restricted to investment-relate
d
employment, and includes any termination in which th
e
allegations are a proximate cause of the separation, even if th
e
individual initiated the separation.
SALES PRACTICE VIOLATIONS shall include any conduct
directed at or involving a customer which would constitute a
violation of: any rules for which a person could be disciplined
by any self-regulatory organization; any provision of the
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Securities Exchange Act of 1934; or any state statute
prohibiting fraudulent conduct in connection with the offer, sale
or purchase of a security or in connection with the rendering of
investment advice.
SELF-REGULATORY ORGANIZATION (“SRO”) means any
national securities or commodities exchange, any national
securities association (e.g., NASD), or any registered clearing
agency.
SPECIFIC INSTRUCTIONS
Completing the Form U4
1. GENERAL INFORMATION
First Name. Enter the individual’s first name. Do not use
nicknames or abbreviations or make modifications to the
individual’s first name.
Middle Name. If the individual has a middle name, specify the
full middle name. Do not use nicknames or abbreviations or
make modifications to the individual’s middle name. If the
individual does not have a middle name, leave this field blank.
Last Name. Enter the individual’s last name. Do not use
nicknames or abbreviations or make modifications to the
individual’s last name. Include punctuation when and where
appropriate.
Suffix. Enter any suffix that follows the individual’s last name,
such as Jr., Sr., etc. Include punctuation when and where
appropriate.
Firm CRD Number. Enter the Firm CRD Number.
Firm Name. Enter the firm’s complete name as listed on the
Form BD or the Form ADV. Do not abbreviate, shorten, or
modify the firm name in any way.
Employment Date. Enter the month, day, and year of hire. Do
not enter the date of application for registration. Your entry
must be numeric (MM/DD/YYYY).
Firm Billing Code. Enter your firm’s billing code. A billing
code is an alpha/numeric value consisting of up to eight
characters that your firm has established. If your firm does not
use billing codes, leave this field blank.
Individual CRD Number. Enter the assigned individual CRD
number.
Individual SSN. Enter the individual’s Social Security Number.
If the individual does not have a CRD number or a Social
Security number, please contact NASD’s Gateway Call Center.
Independent Contractor. Indicate whether the individual will
maintain an independent contractor relationship with the firm
entered in the "Firm Name" field.
Office of Employment Address Street 1/Street 2 and
Supervising Address, if different. If the individual is applying
for registration (or is already registered) with a broker-dealer,
search and select all branch offices with which the individual
will be physically located for business purposes. The NYSE
Branch Code Number (if applicable), Firm Billing Code, branch
office address, and start
/
end dates will prepopulate based on
information provided by the branch office on its Form BR.
If the individual is applying for registration (or is alread
y
registered) with a broker-dealer and will be physically located
for business purposes at a location that is not required to be
registered/notice filed on Form BR, enter the business
location’s Street 1, Street 2, City, State, Country and Postal
Code and search and select the branch office from which this
individual is supervised.
If the individual is applying for registration (or is alread
y
registered) with only an investment-adviser enter the business
location’s Street 1, Street 2, City, State, Country and Postal
Code.
Private Residence Check Box. Check this box if the Office o
f
Employment address is a private residence.
2. FINGERPRINT INFORMATION
Electronic Filing Representation. Select the radio button to
affirm the following: “By selecting this option, I represent that I
am submitting, have submitted, or promptly will submit to the
appropriate SRO a fingerprint card as required unde
r
applicable SRO rules; or, By selecting this option, I represen
t
that I have been employed continuously by the filing firm since
the last submission of a fingerprint card to CRD and am no
t
required to resubmit a fingerprint card at this time; or, By
selecting this option, I represent that I have been employed
continuously by the filing firm and my fingerprints have been
processed by an SRO other than NASD. I am submitting, have
submitted, or promptly will submit the processed results fo
r
posting to CRD.” (Paper filers should skip this representation
and should submit cards with their filing if required to do so.)
Fingerprint Bar Code. Enter the bar code as it appears on the
individual’s fingerprint card. Submission of the bar code is
optional.
Exceptions to the Fingerprint Requirement. If the individual
is not required to submit a fingerprint card with an initial Form
U4, select the radio button that affirms, “By selecting one o
r
more of the following two options, I affirm that I am exemp
t
from the federal fingerprint requirement because I/filing firm
currently satisfy(ies) the requirements of at least one of the
permissive exemptions indicated below pursuant to Rule 17f-2
under the Securities Exchange Act of 1934, including an
y
notice or application requirements specified therein:” and selec
t
one or more of the check boxes:
[ ] Rule 17f-2(a)(1)(i)
[ ] Rule 17f-2(a)(1)(iii)
Investment Adviser Representative Only Applicants.
Contact the specific jurisdiction about any fingerprint
requirements. Complete the following sections:
Investment adviser representative only representation
• I affirm that I am applying only as an
investment adviser representative and that I
am not also applying or have not also applied
with this firm to become a broker-dealer
representative. If this radio button/box is
selected, continue below.
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
• I am applying for registration only in
jurisdictions that do not have fingerprint card
filing requirements, or
• I am applying for registration in jurisdictions
that have fingerprint card filing requirements
and I am submitting, have submitted, or
promptly will submit the appropriate fingerprint
card directly to the jurisdictions for processing
pursuant to applicable jurisdiction rules.
3. REGISTRATION WITH UNAFFILIATED FIRMS
Some jurisdictions prohibit “dual registration,” which occurs
when an individual chooses to maintain a concurrent
registration as a representative/agent with two or more firms
(either BD or IA firms) that are not affiliated. Jurisdictions that
prohibit dual registration would not, for example, permit a
broker-dealer agent working with brokerage firm A to maintain
a registration with brokerage firm B if firms A and B are not
owned or controlled by a common parent. Before seeking a
dual registration status, you should consult the applicable rules
or statutes of the jurisdictions with which you seek registration
for prohibitions on dual registrations or any liability provisions.
Please indicate whether the individual will maintain a “dual
registration” status by answering the questions in this section.
(Note: An individual should answer ‘yes’ only if the individual is
currently registered and is seeking registration with a firm
(either BD or IA) that is not affiliated with the individual’s current
employing firm. If this is an initial application, an individual must
answer ‘no’ to these questions; a “dual registration” may be
initiated only after an initial registration has been established).
A
nswer “yes” or “no” to the following questions:
A
. Will applicant maintain registration with a broker-dealer that
is not affiliated with the filing firm?
If you answer “yes,” list the firm(s) in
Section 12 (EMPLOYMENT HISTORY).
B. Will applicant maintain registration with an investment
adviser that is not affiliated with the filing firm?
If you answer “yes,” list the firm(s) in
Section 12 (EMPLOYMENT HISTORY).
4. SRO REGISTRATION
Investment adviser representative only applicants may
skip this item.
Registration with SRO(s). Indicate with which SRO(s) the
individual seeks to register by selecting the appropriate SRO
registration request box(es).
"Other" Box. See Special Instructions for Paper Filers.
5. JURISDICTION REGISTRATION
Select the type of registration you are seeking: broker dealer
agent (AG) and/or investment adviser representative (RA).
Select the appropriate jurisdiction(s) to register as an AG
and/or an RA.
Agent of an Issuer. If you are seeking registration as an
Agent of an Issuer (AI), select the box marked AI, then ente
r
the two-letter jurisdiction code for each jurisdiction in which you
seek to register. (Note: This instruction applies to paper filers
only.)
6. REGISTRATION REQUESTS WITH
AFFILIATED FIRMS
If the individual seeks registration with firm(s) affiliated with the
filing firm, complete the following to make a request fo
r
registration with the additional affiliated firm(s).
Affiliated Firm CRD Number. Enter the affiliated firm’s CRD
Number.
Affiliated Firm Name. Enter the affiliated firm’s name. This
should be the name of the affiliated firm as listed on the Form
BD or Form ADV. Agents of Issuers should enter the affiliate
d
issuer name in this field. Do not abbreviate, shorten o
r
otherwise modify the firm name in any way.
Affiliated Firm Designation - Broker-Dealer or Investmen
t
Adviser (BD/IA). Select the appropriate radio button (pape
r
filers check the appropriate box) marked as “BD” or “IA” to
indicate whether the affiliated firm is a broker-dealer or an
investment adviser.
Employment Date with Affiliated Firm Enter the month, day,
and year of hire by the affiliated firm. Do not enter the date o
f
application for registration. Your entry must be numeri
c
(MM/DD/YYYY).
Affiliated Firm CRD Branch Number. Enter the branch
number assigned by the CRD system to identify your branch
office with the affiliated firm.
Independent Contractor. Indicate whether the individual will
maintain an independent contractor relationship with the firm
entered in the "Firm Name" field.
Office of Employment Address Street 1 /Street 2 and
Supervising Address, if different. If the individual is applying
for registration (or is already registered) with a broker-dealer,
search and select all branch offices with which the individual
will be physically located. The NYSE Branch Code Number (i
f
applicable), Firm Billing Code, branch office address, and
start/end dates will prepopulate based on information provided
by the branch office on its Form BR.
If the individual is applying for registration (or is alread
y
registered) with a broker-dealer and will be physically located a
t
a location that is not required to be registered/notice filed on
Form BR, enter the business location’s Street 1, Street 2, City,
State, Country and Postal Code and search and select the
branch office from which this individual is supervised.
If the individual is applying for registration (or is alread
y
registered) with only an investment-adviser enter the business
location’s Street 1, Street 2, City, State, Country and Postal
Code..
Designation for Registrations with SROs and Jurisdictions
Identical to Filing Firm. Select this radio button/box to
indicate that you wish to register with the same SROs and
jurisdictions that you registered with for association with the
filing firm.
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Designation for Registrations with SROs and Jurisdictions
that Differ from Your Registrations with Filing Firm. For
electronic filers, select the button/box if you wish to register
with SROs and jurisdictions that differ from your SRO and
j
urisdictions registrations with the filing firm. After you make this
designation, additional screens for SROs and jurisdictions will
appear for you to complete as appropriate.
Fingerprint Information for Affiliated Firms
Electronic or Other Filing Representation. Select a radio
button to affirm: “By selecting this option, I represent that I am
submitting, have submitted, or promptly will submit to the
appropriate SRO a fingerprint card as required under
applicable SRO rules; or, By selecting this option, I represent
that I have been employed continuously by the affiliated firm
since the last submission of a fingerprint card to CRD and am
not required to resubmit a fingerprint card at this time; or, I am
not required to submit a fingerprint card at this time because
the fingerprint card submitted by the filing firm applies; or, By
selecting this option, I represent that I have been employed
continuously by the affiliated firm and my fingerprints have
been processed by an SRO other than NASD. I am submitting,
have submitted, or promptly will submit the processed results
for posting to CRD.
Fingerprint Bar Code. Enter the bar code as it appears on the
individual’s fingerprint card. Submission of the bar code is
optional.
Exceptions to the Fingerprint Requirement. If the individual
is not required to submit a fingerprint card with an initial Form
U4, select the radio button that affirms, “By selecting one or
more of the following two options, I affirm that I am exempt
from the federal fingerprint requirement because I/filing firm
currently satisfy(ies) the requirements of at least one of the
permissive exemptions indicated below pursuant to Rule 17f-2
under the Securities Exchange Act of 1934, including any
notice or application requirements specified therein:” and select
one or more of the check boxes:
[ ] Rule 17f-2(a)(1)(i)
[ ] Rule 17f-2(a)(1)(iii)
Investment Adviser Representative Only Applicants
• I affirm that I am applying only as an investment
adviser representative and that I am not also
applying or have not also applied with this firm to
become a broker-dealer representative. If this radio
button/box is selected, continue below.
• I am applying for registration only in
jurisdictions that do not have fingerprint card
filing requirements, or
• I am applying for registration in jurisdictions
that have fingerprint card filing requirements
and I am submitting, have submitted, or
promptly will submit the appropriate fingerprint
card directly to the jurisdictions for processing
pursuant to applicable jurisdiction rules.
7. EXAMINATION REQUESTS
Scheduling or Rescheduling Examinations. Complete this
section only if you are scheduling or rescheduling an
examination or continuing education session. Do not select the
Series 63 (S63) or Series 65 (Series 65) examinations in this
section if you have completed Section 5 (JURISDICTION
REGISTRATION) and have selected registration in a
jurisdiction. If you have completed Section 5 (JURISDICTION
REGISTRATION), and requested an AG registration in a
jurisdiction that requires that you pass the S63 examination, an
S63 examination will be automatically scheduled for you upon
submission of this Form U4. If you have completed Section 5
(JURISDICTION REGISTRATION), and requested an RA
registration in a jurisdiction that requires that you pass the S65
examination, an S65 examination will be automatically
scheduled for you upon submission of this Form U4.
"Other" Box. Paper filers should check the “Other” box only to
request other examinations not currently listed on the Form U4.
8. PROFESSIONAL DESIGNATIONS
Select the designation(s) you currently maintain. If you
maintain one or more of the designations listed in Section 8
(PROFESSIONAL DESIGNATIONS), you may be eligible for a
waiver from the examination(s) required to become an RA.
Refer to the UNIFORM FORMS REFERENCE GUIDE fo
r
additional information about designations. Note: This field is
optional unless you are seeking a waiver from the
examination(s) required to become an RA.
9. IDENTIFYING INFO RMATION/NAME
CHANGE
This section will be pre-populated with the identifying
information provided in Section 1 (GENERAL INFORMATION).
If the individual's name has changed, enter the new name.
First Name. Enter the individual’s first name. Do not use
nicknames or abbreviations or make modifications to the
individual’s first name.
Middle Name. If the individual has a middle name, specify the
full middle name. Do not use nicknames or abbreviations o
r
make modifications to the individual’s middle name. If the
individual does not have a middle name, leave this field blank.
Last Name. Enter the individual’s last name. Do not use
nicknames or abbreviations or make modifications to the
individual’s last name. Include punctuation when and where
appropriate.
Suffix. Enter any suffix that follows the individual’s last name,
such as Jr., Sr., etc. Include punctuation when and where
appropriate.
Date of Birth. Enter your date of birth. Your entry must be
numeric (MM/DD/YYYY).
State/Province of Birth. Enter the name of the state o
r
province where you were born.
Country of Birth. Enter the name of the country where you
were born.
Sex. Select the appropriate button to indicate your gender.
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13. OTHER BUSINESS
INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Height (ft)/(in). Enter your height, measured in feet and
inches.
Weight (lbs). Enter your weight, measured in pounds.
Hair Color. Enter your hair color.
Eye Color. Enter your eye color.
10. OTHER NAMES
Enter all other names that you have used or are using, or by
which you are known or have been known, other than your
legal name, since the age of 18. This field must include, for
example, nicknames, aliases, and names used before or after
marriage.
11. RESIDENTIAL HISTORY
Provide your residential addresses for the past five (5) years.
Leave no gaps greater than three (3) months between
addresses. Begin by entering your current residential address.
Enter "Present" as the end date for your current address. Post
Office boxes are not acceptable. Report changes as they
occur.
From (MM/YYYY). Enter the month and year you began
residing at this address.
To (MM/YYYY). Enter the month and year you stopped
residing at this address. Enter "Present" as the end date for
your current address.
Street Address 1/Street Address 2. Enter your street
address here. Post office boxes are not acceptable. Include the
street name; building name or number; and unit, suite,
apartment or condominium number, as applicable; as well as
other identifying information. Continue on Street Address 2 if
you need more space.
City. Enter your city.
State. Enter the state of residence relating to this address.
Country. Enter the name of the country of residence for this
address.
Postal Code. Enter the postal code for this address.
12. EMPLOYMENT HISTORY
Provide your employment and personal history for the past ten
(10) years. Leave no gaps greater than three (3) months
between entries. All entries must include the beginning and end
dates of employment. Begin by entering your current
employment. Enter "Present" as the end date for your current
employment. Include in your response the firm named in
Section 1 (GENERAL INFORMATION); the firm(s) named in
Section 3 (REGISTRATION WITH UNAFFILIATED FIRMS);
and the firm(s) named in Section 6 (REGISTRATION
REQUESTS WITH AFFILIATED FIRMS). Account for full-time
and part-time employment, self-employment, military service,
and homemaking. Include unemployment, full-time education,
extended travel, and other similar statuses.
From (MM/YYYY). Enter the month and year you started this
position. Your entry must be numeric (MM/DD/YYYY).
To (MM/YYYY). Enter the month and year you ended this
position. Your entry must be numeric (MM/DD/YYYY). Ente
r
"Present" as the end date for your current employment.
Name. Enter the name of the employing firm or company fo
r
this position.
City. Enter the name of the city where you are/were employed
in this position.
State. Enter the name of the state where you are/were
employed in this position. Paper filers should enter the two-
character state identification.
Country. Enter the name of the country where you are/were
employed in this position.
Investment-Related Business. Enter “yes” or “no” to indicate
whether the employer is or was an investment-related business
at the time of your employment, regardless of the position tha
t
you hold or held at the time of employment.
Position Held. Enter your last title or position held with this
employer.
Enter “yes” or “no” to indicate whether you currently are
engaged in any other business, either as a proprietor, partner,
officer, director, employee, trustee, agent, or otherwise.
Exclude non-investment-related activity that is exclusively
charitable, civic, religious or fraternal, and is recognized as ta
x
exempt. If you answer “yes” to this question, provide the
following information:
• name and address of the other business
• the nature of the other business, including whether it
is investment-related
• your position, title, or association with the othe
r
business, including your duties
• the start date of your relationship with the othe
r
business
• the approximate number of hours per month you
devote to the other business
• the number of hours you devote to the othe
r
business during securities trading hours
14. DISCLOSURE QUESTIONS
Check the appropriate “yes” or “no” response for each
question. Provide complete details explaining any “yes”
answers on the appropriate Disclosure Reporting Pages
(DRPs).
Note that an affirmative answer to certain disclosure questions
may make an individual subject to a statutory disqualification
as defined in Section 3(a)(39) and Section 15(b)(4) of the
Securities Exchange Act of 1934.
Questions 14D(1) and 14D(2) are not mutually exclusive. For
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
purposes of Question 14D(1), state regulatory agency means
any state regulatory agency and is not limited to state financial
regulatory agencies. For purposes of Question 14D(2), all
terms have the same meanings as intended by Congress and
interpreted by the U.S. Securities and Exchange Commission
under parallel provisions contained in Section 3(a)(39) and
Section 15(b)(4) of the Securities Exchange Act of 1934.
Criminal Disclosure
14A - Felony Criminal Disclosure
14B - Misdemeanor Criminal Disclosure
Regulatory Action Disclosure
14C - Regulatory Action by SEC or CFTC
14D(1) - Regulatory Action by other federal regulator,
state regulator, or foreign financial regulator
14D(2) – Final order of state securities commission,
state authority that supervises or examines banks,
savings associations, or credit unions, state
insurance commission, appropriate Federal
Banking agency, or National Credit Union
Administration
14E - Regulatory Action by SRO or commodities
exchange
14F - Professional Suspension
14G - Formal Pending Action/Investigation
Civil Judicial Disclosure
14H - Civil Judicial Actions
Customer Complaint/Arbitration/Civil Litigation Disclosure
14I - Customer Complaints
Termination Disclosure
14J - Terminations for Cause
Financial Disclosure
14K – Bankruptcy, SIPC and Compromise with
Creditors
14L - Bonding Payouts or Revocations
14M - Unsatisfied Judgments and Liens
15. SIGNATURES
Please Read Carefully. All signatures required on this Form
U4 filing must be made in this section. A “signature” includes a
manual signature or an electronically transmitted equivalent.
For purposes of an electronic form filing, a signature is effected
by typing a name in the designated signature field. By typing a
name in this field, the signatory acknowledges and represents
that the entry constitutes in every way, use, or aspect, his or
her legally binding signature. The form includes signature fields
for the individual/applicant and for the Appropriate Signatory.
Firms are responsible for obtaining the individual/applicant’s
consent to the undertakings and attestations enumerated in
Section 15A (INDIVIDUAL/APPLICANT'S
A
CKNOWLEDGMENT AND CONSENT). Firms also are
responsible for complying with all records retention
requirements applicable to this form. When making entries in
this section, both the Date and Name/Signature fields must be
completed as follows:
Date. For individual/applicant, enter the date that the
application or amendment is being signed. For
Appropriate Signatory entries, enter the date that the
application or amendment is being filed. Entries must
be numeric (MM/DD/YYYY). Future dates may not
be entered in this section.
Name/Signature of Individual or
A
ppropriate
Signatory.
Enter the name of the individual or the
Appropriate Signatory. The signatory’s full legal
name must be displayed under the signature. The
name must be typed or printed as it appears in
signature form. By typing a name in this field, the
signatory acknowledges that this entry constitutes in
every way, use, or aspect, his or her legally binding
signature.
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGMENT AND
CONSENT.
This section must be completed on all initial o
r
Temporary Registration form filings.
15B. FIRM/APPROPRIATE SIGNATORY
REPRESENTATIONS.
This section must be completed on all initial o
r
Temporary Registration form filings.
15C. TEMPORARY REGISTRATION ACKNOWLEDGMENT.
This section must be completed on Temporar
y
Registration form filings to be able to receive
Temporary Registration.
15D. INDIVIDUAL/APPLICANT'S AMENDMENT
ACKNOWLEDGMENT AND CONSENT.
This section must be completed on any amendment
filing that amends any information in Section 14
(Disclosure Questions) or any Disclosure Reporting
Page (DRP).
15E. FIRM/APPROPRIATE SIGNATORY AMENDMENT
REPRESENTATIONS.
This section must be completed on all amendmen
t
form filings.
15F. FIRM/APPROPRIATE SIGNATORY CONCURRENCE.
This section must be completed to concur with a U4
filing made by another firm (IA/BD) on behalf of an
individual that is also registered with that other firm
(IA/BD).
APPENDIX
Drop-Down Pick Lists
General
State: Alabama, Alaska, Arizona, Arkansas, California,
Colorado, Connecticut, Delaware, District of Columbia, Florida,
Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas,
Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Mississippi, Missouri, Montana,
Nebraska, Nevada, New Hampshire, New Jersey, New Mexico,
New York, North Carolina, North Dakota, Ohio, Oklahoma,
Oregon, Pennsylvania, Puerto Rico, Rhode Island, South
Carolina, South Dakota, Tennessee, Texas, Utah, Vermont,
Virginia, Washington, West Virginia, Wisconsin, Wyoming.
Identifying Information/Name Changes
Hair Color: Bald, black, blonde or strawberry, brown, gray o
r
partially gray, red/auburn, sandy, white, unknown, blue, green,
orange, pink, purple.
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Eye Color: Black, blue, brown, gray, green, hazel, maroon,
multicolored, pink, unknown
.
DRPs
Bankruptcy/SIPC/Compromise with Creditors
Action Type: Bankruptcy, compromise, declaration,
liquidated, other, receivership.
If not pending, provide disposition type: Direct Payment
Procedure, Discharged, Dismissed, Dissolved, Other,
SIPA Trustee Appointed, Satisfied/Released.
Bond
Disposition Type: Denied, Payout, Revoked.
Civil Judicial
Principal relief sought: Cease and Desist, Civil
Penalty(ies)/Fine(s), Disgorgement, Injunction, Money
Damages (Private/Civil Complaint), Other, Restitution,
Restraining Order.
Principal product type: Annuity(ies)-Fixed, Annuity(ies)-
Variable, Banking Products (Other than CDs), CD(s),
Commodity Option(s), Debt-Asset Backed, Debt-
Corporate, Debt-Government, Debt-Municipal,
Derivative(s), Direct Investment(s)-DDP & LP Interest(s),
Equity-OTC, Equity Listed (Common & Preferred Stock),
Futures-Commodity, Futures-Financial, Index Option(s),
Insurance, Investment Contract(s), Money Market
Fund(s), Mutual Fund(s), No Product, Options, Other,
Penny Stock(s), Unit Investment Trust(s).
How was matter resolved: Consent, Dismissed, Judgment
Rendered, Opinion, Other, Settled, Withdrawn.
Customer Complaint/Arbitration/Civil Litigation
Customer’s state of residence: Alabama, Alaska, Arizona,
Arkansas, California, Colorado, Connecticut, Delaware,
District of Columbia, Florida, Georgia, Hawaii, Idaho,
Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana,
Maine, Maryland, Massachusetts, Michigan, Minnesota,
Mississippi, Missouri, Montana, Nebraska, Nevada, New
Hampshire, New Jersey, New Mexico, New York, North
Carolina, North Dakota, Ohio, Oklahoma, Oregon,
Pennsylvania, Puerto Rico, Rhode Island, South Carolina,
South Dakota, Tennessee, Texas, Utah, Vermont,
Virginia, Washington, West Virginia, Wisconsin, Wyoming
Principal product type: Annuity(ies)-Fixed, Annuity(ies)-
Variable, Banking Products (Other than CDs), CD(s),
Commodity Option(s), Debt-Asset Backed, Debt-
Corporate, Debt-Government, Debt-Municipal,
Derivative(s), Direct Investment(s)-DDP & LP Interest(s),
Equity-OTC, Equity Listed (Common & Preferred Stock),
Futures-Commodity, Futures-Financial, Index Option(s),
Insurance, Investment Contract(s), Money Market
Fund(s), Mutual Fund(s), No Product, Options, Other,
Penny Stock(s), Unit Investment Trust(s).
If the arbitration is not pending, what was the
disposition?: Award to Applicant, Award to Customer,
Decision for Applicant, Decision for Customer, Denied,
Dismissed, Judgment (other than monetary), No Action,
Other, Settled, Withdrawn.
If the litigation is not pending, what was the disposition?:
Decision for Applicant, Decision for Customer, Denied,
Dismissed, Judgment (other than monetary), Monetary
Judgment to Applicant, Monetary Judgment to Customer,
No Action, Other, Settled, Withdrawn.
Judgment/Lien
Judgment/Lien Type: Civil, Default, Tax.
If no, how was matter resolved?: Discharged, Released,
Removed, Satisfied.
Regulatory Action
Principal Sanction: Cease and Desist, Civil
Penalty(ies)/Fine(s), Disgorgement, Injunction, Money
Damages (Private/Civil Complaint), Other, Restitution,
Restraining Order.
Principal product type: Annuity(ies)-Fixed, Annuity(ies)-
Variable, Banking Products (Other than CDs), CD(s),
Commodity Option(s), Debt-Asset Backed, Debt-
Corporate, Debt-Government, Debt-Municipal,
Derivative(s), Direct Investment(s)-DDP & LP Interest(s),
Equity-OTC, Equity Listed (Common & Preferred Stock),
Futures-Commodity, Futures-Financial, Index Option(s),
Insurance, Investment Contract(s), Money Market
Fund(s), Mutual Fund(s), No Product, Options, Other,
Penny Stock(s), Unit Investment Trust(s).
How was matter resolved: Acceptance, Waiver & Consent
(AWC), Consent, Decision, Decision & Order of Offer of
Settlement, Dismissed, Order, Other, Settled, Stipulation
and Consent, Vacated, Withdrawn.
Termination
Termination Type: Discharged, Permitted to Resign,
Voluntary Resignation.
Principal product type: Annuity(ies)-Fixed, Annuity(ies)-
Variable, Banking Products (Other than CDs), CD(s),
Commodity Option(s), Debt-Asset Backed, Debt-
Corporate, Debt-Government, Debt-Municipal,
Derivative(s), Direct Investment(s)-DDP & LP Interest(s),
Equity-OTC, Equity Listed (Common & Preferred Stock),
Futures-Commodity, Futures-Financial, Index Option(s),
Insurance, Investment Contract(s), Money Market
Fund(s), Mutual Fund(s), No Product, Options, Other,
Penny Stock(s), Unit Investment Trust(s).
SPECIAL INSTRUCTIONS FOR PAPER
FILERS
If you plan to file the Form U4 on paper rather than
electronically through Web CRD or IARD, please refer to the
following instructions for paper filings. These instructions
should be read in conjunction with the other instructions
(General Instructions, Specific Instructions, and the
Explanation of Terms) contained in this Form U4. Please note
that paper filings generally are not permitted for broker-deale
r
registrations.
Submission of Forms
When applying for the first time, you must file a complete Form
U4. To amend your Form U4, you must:
• Complete Section 1 (GENERAL INFORMATION).
• Update/amend the appropriate section(s) of the Form
U4.
• Update/amend the appropriate Disclosure Reporting
Pages.
• Include necessary signatures.
•
Submit the amendment to the appropriate SRO o
r
jurisdictions.
The firm must retain and, upon request, must make available
for regulatory inspection, a copy of the signed initial Form U4
and a copy of each amendment to the Form U4.
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INSTRUCTIONS Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
1. GENERAL INFORMATION
You should note the following:
Individual CRD Number. Provide the individual’s CRD
number that was generated by the CRD system for the
individual. If the individual’s CRD number has not been
generated or is not known, leave this item blank.
Firm CRD Number. Provide the firm’s CRD number that was
generated by the CRD system for the firm. If the firm’s CRD
number has not been generated or is not known, leave this
item blank.
Firm Name. If you are an Agent of an Issuer, enter in the field
labeled “Firm Name” the name of the issuer of the securities
whom you represent. Do not abbreviate, shorten, or modify the
name in any way.
CRD Branch Number. This is not a required field.
2. FINGERPRINT INFORMATION
You must submit to the appropriate SRO or jurisdiction
fingerprint cards if required to do so.
4. & 5. REGISTRATIONS
• Select the appropriate SRO or jurisdiction registration
category with whom you are seeking registration by
selecting the appropriate request box(es).
• If you are an Agent of an Issuer (AI), select the box
marked AI; then enter the two-letter jurisdiction
identification for the relevant state(s). Contact the
appropriate jurisdiction for instructions regarding AI
registration processing.
• Use the “Other” box only to request registration
categories not listed on the Form U4.
• Applicable fees should be submitted with your filing.
6. REGISTRATION REQUESTS WITH
AFFILIATED FIRMS
This section does not apply for paper filers.
7. EXAMINATION REQUESTS
Check the “Other” box only to request examination categories
not listed on the Form U4.
9. IDENTIFYING INFORMATION/NAME
CHANGE
Hair Color. Enter your hair color from the list of choices
appended to this form.
Eye Color. Enter your eye color from the list of choices
appended to this form.
15F. FIRM/APPROPRIATE S IGNATORY
CONCURRENCE
This section does not apply for paper filers.
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Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
1. GENERAL INFORMATION
Private Residence Check Box: If the Office of Em
ployment address is a private residence, check this box.
2. FINGERPRINT INFORMATION
FIRST NAME:
FIRM
CRD #:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
MIDDLE NAME:
FIRM NAME:
INDIVIDUAL CRD #
:
LAST NAME:
EMPLOYMENT DATE (MM/DD/YYYY):
INDIVIDUAL SSN:
CITY:
COUNTRY:
SUFFIX:
STATE:
POSTAL CODE:
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Supervised From
Located At
START DATE: END DATE:
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Supervised From
Located At
START DATE: END DATE:
STATE: CITY:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
COUNTRY: POSTAL CODE:
FIRM
Billing Code:
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Supervised From
Located At
START DATE: END DATE:
STATE: CITY:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
COUNTRY: POSTAL CODE:
Electronic Filing Representation
By selecting this option, I represent that I am submitting, have submitted, or promptly will submit to the appropriate SRO a
fingerprint card as required under applicable SRO rules; or
Fingerprint card barcode __________________________________________________
Exceptions to the Fingerprint Requirement
By selecting one or more of the following two options, I affirm that I am exempt from the federal fingerprint requirement because
I/filing firm currently satisfy(ies) the requirements of at least one of the permissive exemptions indicated below pursuant to Rule 17f-2
under the Securities Exchange Act of 1934, including any notice or application requirements specified therein:
Rule 17f-2
(
a
)(
1
)(
i
)
Rule 17f-2
(
a
)(
1
)(
iii
)
Investment Adviser Representative Only Applicants
I affirm that I am applying only as an investment adviser representative and that I am not also applying or have not also applied
with this firm to become a broker-dealer representative. If this radio button/box is selected, continue below.
I am applying for registration only in jurisdictions that do not have fingerprint card filing requirements, or
I am applying for registration in jurisdictions that have fingerprint card filing requirements and I am submitting, have
submitted, or promptly will submit the appropriate fingerprint card directly to the jurisdictions for processing pursuant to
applicable jurisdiction rules.
By selecting this option, I represent that I have been employed continuously by the filing firm since the last submission of a fingerprint
card to CRD and am not required to resubmit a fingerprint card at this time; or,
By selecting this option, I represent that I have been employed continuously by the filing firm and my fingerprints have been
processed by an SRO other than NASD. I am submitting, have submitted, or promptly will submit the processed results for posting
to CRD.
Do you have an independent contractor relationship with the above named firm?:
Yes No
Office of Employment Address:
Private Residence Check Box: If the Office of Employment address is a private residence, check this box.
Private Residence Check Box: If the Office of Em
ployment address is a private residence, check this box.
Page 1 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
3. REGISTRATION WITH UNAFFILIATED FIRMS
Some jurisdictions prohibit "dual registration," which occurs when an individual chooses to maintain a concurrent registration as a represen-
tative/agent with two or more firms (either BD or IA firms) that are not affiliated. Jurisdictions that prohibit dual registration would not, for
example, permit a broker-dealer agent working with brokerage firm A to maintain a registration with brokerage firm B if firms A and B are not
owned or controlled by a common parent. Before seeking a dual registration status, you should consult the applicable rules or statutes of
the jurisdictions with which you seek registration for prohibitions on dual registrations or any liability provisions.
Please indicate whether the individual will maintain a "dual registration" status by answering the questions in this section. (Note: An
individual should answer 'yes' only if the individual is currently registered and is seeking registration with a firm (either BD or IA) that is not
affiliated with the individual's current employing firm. If this is an initial application, an individual must answer 'no' to these questions; a "dual
registration" may be initiated only after an initial registration has been established).
Answer "yes" or "no" to the following questions:
A. Will applicant
maintain registration with a broker-dealer that is not affiliated with the filing firm?
If you answer "yes," list the firm(s) in Section 12 (Employment History).
B. Will applicant maintain registration with an investment adviser that is not affiliated with the filing firm?
If you answer "yes," list the firm(s) in Section 12 (Employment History).
Yes
No
Page 2 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
4. SRO REGISTRATIONS
Check appropriate SRO Registration requests.
Qualifying examinations will be automatically scheduled if needed. If you are only scheduling or re-scheduling an exam, skip this section and
complete Section 7 (EXAMINATION REQUESTS).
REGISTRATION CATEGORY NASD NYSE AMEX BSE NSX PCX CBOE CHX PHLX ISE
OP - Registered Options Principal (S4)
IR - Investment Company & Variable Contracts Products Rep. (S6)
GS - Full Registration/General Securities Representative (S7)
TR - Securities Trader (S7)
TS - Trading Supervisor (S7)
SU - General Securities Sales Supervisor (S9 and S10)
BM - Branch Office Manager (S9 and S10)
SM - Securities Manager (S12)
AR - Assistant Representative/Order Processing (S11)
IE - United Kingdom-Limited General Securities Registered Representative (S17)
DR - Direct Participation Program Representative (S22)
GP - General Securities Principal (S24)
IP - Investment Company and Variable Contracts Products Principal (S26)
FA - Foreign Associate
FN - Financial and Operations Principal (S27)
FI - Introducing Broker-Dealer/Financial and Operations Principal (S28)
RS - Research Analyst (S86,S87)
RP - Research Principal
DP - Direct Participation Program Principal (S39)
OR - Operations Representative (S42)
MR - Municipal Securities Representative (S52)
MP - Municipal Securities Principal (S53)
CS - Corporate Securities Representative (S62)
RG - Government Securities Representative (S72)
PG - Government Securities Principal (S73)
SA - Supervisory Analyst (S16)
PR - Limited Representative - Private Securities Offerings (S82)
CD - Canada-Limited General Securities Registered Representative (S37)
CN - Canada-Limited General Securities Registered Representative (S38)
ET - Equity Trader (S55)
AM - Allied Member
AP - Approved Person
LE - Securities Lending Representative
LS - Securities Lending Supervisor
ME - Member Exchange
FE - Floor Employee
OF - Officer
CO - Compliance Official (S14)
CF - Compliance Official Specialist (S14A)
PM - Floor Member Conducting Public Business
PC - Floor Clerk Conducting Public Business
SC - Specialist Clerk (S21)
TA - Trading Assistant (S25)
SF - Single Stock Futures (S43)
FP - Municipal Fund (S51)
IF - In-Firm Delivery Proctor
MM - Market Maker
FB - Floor Broker
MB - Market Maker Acting as Floor Broker
Other__________________________________ (Paper Form Only)
Page 3 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
5. JURISDICTION REGISTRATIONS
Check appropriate jurisdiction(s) for broker-dealer agent (AG) and/or investment adviser representative (RA) registration requests.
JURISDICTION
AG
RA JURISDICTION
AG RA
JURISDICTION
AG
RA
JURISDICTION
AG
RA
A
labama
A
laska
A
rizona
A
rkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
A
GENT OF THE ISSUER REGISTRATION (AI) Indicate 2 letter jurisdiction code(s):___________
Page 4 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
6. REGISTRATION REQUESTS WITH AFFILIATED FIRMS
Will applicant maintain registration with firm(s) under common ownership or control with the filing firm?
Yes No
If "yes", fill in the details to indicate a request for registration with additional firm(s).
If the individual seeks registration with firm(s) affiliated with the filing firm, complete the following to make a request for registration with
the additional affiliated firm(s) other than the filing firm.
AFFILIATED FIRM
CRD #:
EMPLOYMENT DATE:
AFFILIATED FIRM
BILLING CODE:
AFFILIATED FIRM
NAME:
Do you have an independent contractor relationship with the above named
Yes No
firm?:
Office of Employment Address:
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Located At
Supervised From
START DATE: END DATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
CITY: STATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
COUNTRY: POSTAL CODE:
Private Residence Check Box: If the Office of Employment address is a private residence, check this box.
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Located At
Supervised From
START DATE: END DATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
CITY: STATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
COUNTRY: POSTAL CODE:
Private Residence Check Box: If the Office of Employment address is a private residence, check this box.
Registered
Non-Registered
CRD BRANCH #: NYSE BRANCH CODE #:
FIRM
BILLING CODE:
Located At
Supervised From
START DATE: END DATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 1:
CITY: STATE:
OFFICE OF EMPLOYMENT ADDRESS STREET 2:
COUNTRY: POSTAL CODE:
Private Residence Check Box: If the Office of Employment address is a private residence, check this box.
Check here to request the same SRO and jurisdiction registrations for this affiliated firm that are requested on this application for the
filing firm.
Check here to request different SRO and jurisdiction registrations than requested on this application for your filing firm.
Page 5 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
AFFILIATED FIRM FINGERPRINT INFORMATION
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
Electronic Filing Representation
By selecting this option, I represent that I am submitting, have submitted, or promptly will submit to the appropriate SRO a
fingerprint card as required under applicable SRO rules; or,
Fingerprint card barcode __________________________________________________
Exceptions to the Fingerprint Requirement
By selecting one or more of the following two options, I affirm that I am exempt from the federal fingerprint requirement because
I/filing firm currently satisfy(ies) the requirements of at least one of the permissive exemptions indicated below pursuant to Rule
17f-2 under the Securities Exchange Act of 1934, including any notice or application requirements specified therein:
Rule 17f-2
(a)(1)(i)
Rule 17f-2(a)(1)(iii)
Investment Adviser Representative Only Applicants
I affirm that I am applying only as an investment adviser representative and that I am not also applying or have not also applied
with this firm to become a broker-dealer representative. If this radio button/box is selected, continue below.
I am applying for registration only in jurisdictions that do not have fingerprint card filing requirements, or
I am applying for registration in jurisdictions that have fingerprint card filing requirements and I am submitting, have
submitted, or promptly will submit the appropriate fingerprint card directly to the jurisdictions for processing pursuant to
applicable jurisdiction rules.
By selecting this option, I represent that I have been employed continuously by the affiliated firm since the last submission of a
fingerprint card to CRD and am not required to resubmit a fingerprint card at this time; or,
By selecting this option, I represent that I have been employed continuously by the affiliated firm and my fingerprints have been
processed by an SRO other than NASD. I am submitting, have submitted, or promptly will submit the processed results for
posting to CRD.
I am not required to submit a fingerprint card at this time because the fingerprint card submitted by the filing firm applies; or,
7. EXAMINATION REQUESTS
Scheduling or Rescheduling Examinations. Complete this section only if you are scheduling or rescheduling an examination or
continuing education session. Do not
select the Series 63 (S63) or Series 65 (S65) examinations in this section if you have completed
Section 5 (JURISDICTION REGISTRATION) and have selected registration in a jurisdiction. If you have completed Section 5
(JURISDICTION REGISTRATION), and requested an AG registration in a jurisdiction that requires that you pass the S63 examination, an
S63 examination will be automatically scheduled for you upon submission of this Form U4. If you have completed Section 5
(JURISDICTION REGISTRATION), and requested an RA registration in a jurisdiction that requires that you pass the S65 examination, an
S65 examination will be automatically scheduled for you upon submission of this Form U4.
S3
S4
S5
S6
S7
S7
A
S9
S10
S11
S12
S14
S14
A
S15
S16
S17
S21
S22
S23
S24
S25
S26
S27
S28
S30
S31
S32
S33
S37
S38
S39
S42
S43
S44
S45
S46
S51
S52
S53
S55
S62
S63
S65
S66
S72
S73
S82
S86
S87
S101
S106
S201
Other______________________________________ (Paper Form Only)
OPTIONAL: Foreign Exam City______________________________ Date (MM/DD/YYYY) __________________________
If you have taken an exam prior to registering through the CRD system enter the exam type and date taken.
Exam type:___________________________________________ Date taken (MM/DD/YYYY):____________________________
8. PROFESSIONAL DESIGNATIONS
Select each designation you currently maintain.
Certified Financial Planner
Chartered Financial Consultant (ChFC)
Personal Financial Specialist (PFS)
Chartered Financial Analyst (CFA) Chartered Investment Counselor (CIC)
Page 6 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
9. IDENTIFYING INFORMATION/NAME CHANGE
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
DATE OF BIRTH (MM/DD/YYYY): STATE/PROVINCE OF BIRTH: COUNTRY OF BIRTH: SEX:
MALE FEMALE
HEIGHT (FT): HEIGHT (IN): WEIGHT (LBS): HAIR COLOR: EYE COLOR:
10. OTHER NAMES
Enter all other names that you have used or are using, or by which you are known or have been known, other than your legal name, since the
age of 18. This field should include, for example, nicknames, aliases, and names used before or after marriage.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
Page 7 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
11. RESIDENTIAL HISTORY
Starting with the current address, give all addresses for the past 5 years. Report changes as they occur.
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY:
STATE:
COUNTRY:
POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
FROM (MM/YYYY): TO (MM/YYYY): STREET ADDRESS 1: STREET ADDRESS 2:
CITY: STATE: COUNTRY: POSTAL CODE:
Page 8 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
12. EMPLOYMENT HISTORY
Provide complete employment history for the past 10 years. Include the firm(s) noted in Section 1 (GENERAL INFORMATION) and Section
6 (REGISTRATION REQUESTS WITH AFFILIATED FIRMS). Include all firm(s) from Section 3 (REGISTRATION WITH UNAFFILIATED
FIRMS). Account for all time including full and part-time employments, self-employment, military service, and homemaking. Also include
statuses such as unemployed, full-time education, extended travel, or other similar statuses.
Report changes as they occur.
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF FIRM OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF FIRM OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY:
INVESTMENT-RELATED
BUSINESS?
Yes No
POSITION HELD:
FROM (MM/YYYY): TO (MM/YYYY): NAME OF
FIRM
OR COMPANY: CITY:
STATE: COUNTRY: INVESTMENT-RELATED BUSINESS?
Yes No
POSITION HELD:
Page 9 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
13. OTHER BUSINESS
A
re you currently engaged in any other business either as a proprietor, partner, officer, director, employee, trustee, agent or otherwise?
(Please exclude non investment-related activity that is exclusively charitable, civic, religious or fraternal and is recognized as tax exempt.)
If YES, please provide the following details: the name of the other business, whether the business is investment-related, the address of the
other business, the nature of the other business, your position, title, or relationship with the other business, the start date of your
relationship, the approximate number of hours/month you devote to the other business, the number of hours you devote to the other
business during securities trading hours, and briefly describe your duties relating to the other business.
No
If "Yes," please enter details below.
Yes
Page 10 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
14. DISCLOSURE QUESTIONS
IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS 'YES',
COMPLETE DETAILS OF ALL EVENTS OR PROCEEDINGS ON APPROPRIATE DRP(S)
REFER TO THE EXPLANATION OF TERMS SECTION OF FORM U4 INSTRUCTIONS FOR EXPLANATIONS OF ITALICIZED TERMS.
YES NO
Criminal Disclosure
14A. (1) Have you ever:
(a) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court
to any felony?
(b) been charged with any felony?
(2) Based upon activities that occurred while you exercised
control
over it, has an organization ever:
(a) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic or foreign court to any
felony?
(b) been charged with any felony?
14B. (1) Have you ever:
(a) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign or military court to
a misdemeanor involving: investments or an investment-related business or any fraud, false statements
or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a
conspiracy to commit any of these offenses?
(b) been charged with a misdemeanor specified in 14B(1)(a)?
(2)
Based upon activities that occurred while you exercised
control
over it, has an organization ever:
(a) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic or foreign court to a
misdemeanor specified in 14B(1)(a)?
(b) been charged with a misdemeanor specified in 14B(1)(a)?
Regulatory Action Disclosure
14C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever:
(1) found you to have made a false statement or omission?
(2) found you to have been involved in a violation of its regulations or statutes?
(3) found you to have been a cause of an investment-related business having its authorization to do business
denied, suspended, revoked, or restricted?
(4) entered an order against you in connection with investment-related activity?
(5) imposed a civil money penalty on you, or ordered you to cease and desist from any activity?
14D. (1)
Has any other Federal regulatory agency or any state regulatory agency or
foreign financial regulatory
authorit
y
ever:
(a) found you to have made a false statement or omission or been dishonest, unfair or unethical?
(b) found you to have been involved in a violation of investment-related regulation(s) or statute(s)?
(c) found you to have been a cause of an investment-related business having its authorization to do
business denied, suspended, revoked or restricted?
(d) entered an order against you in connection with an investment-related activity?
(e) denied, suspended, or revoked your registration or license or otherwise, by order, prevented you from
associating with an investment-related business or restricted your activities?
(2) Have you been subject to any
final order
of a state securities commission (or any agency or office
performing like functions), state authority that supervises or examines banks, savings associations, or
credit unions, state insurance commission (or any agency or office performing like functions), an
appropriate federal banking agency, or the National Credit Union Administration, that:
(a) bars you from association with an entity regulated by such commission, authority, agency, or officer, or
from engaging in the business of securities, insurance, banking, savings association activities, or credit
union activities; or
(b) (b) constitutes a final order based on violations of any laws or regulations that prohibit fraudulent,
manipulative, or deceptive conduct?
14E. Has any self-regulatory organization or commodities exchange ever:
(1) found you to have made a false statement or omission?
(2) found you to have been involved in a violation of its rules (other than a violation designated as a "minor rule
violation" under a plan approved by the U.S. Securities and Exchange Commission)?
(3) found you to have been the cause of an investment-related business having its authorization to do business
denied, suspended, revoked or restricted?
(4) disciplined you by expelling or suspending you from membership, barring or suspending your association with
its members, or restricting your activities?
Page 11 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
14. DISCLOSURE QUESTIONS (CONTINUED)
YES NO
14F.
14G.
Have you ever had an authorization to act as an attorney, accountant or federal contractor that was
revoked or suspended?
Have you been notified, in writing, that you are now the subject of any:
(1) regulatory complaint or proceeding that could result in a "yes" answer to any part of 14C, D or E? (If "yes",
complete the Regulatory Action Disclosure Reporting Page.)
(2)
investigation that could result in a "yes" answer to any part of 14A, B, C, D or E? (If "yes", complete the
Investigation Disclosure Reporting Page.)
Civil Judicial Disclosure
14H. (1) Has any domestic or foreign court ever:
(a) enjoined you in connection with any investment-related activity?
(b) found that you were involved in a violation of any investment-related statute(s) or regulation(s)?
(c)
dismissed, pursuant to a settlement agreement, an investment-related civil action brought against you by a
state or foreign financial regulatory authority?
(2)
Are you named in any pending
investment-related
civil action that could result in a "yes" answer to any
part of 14H(1)?
Customer Complaint/Arbitration/Civil Litigation Disclosure
14I. (1)
Have you ever been named as a respondent/defendant in an
investment-related,
consumer-initiated
arbitration or civil litigation which alleged that you were involved in one or more sales practice violations
and which:
(a) is still pending, or;
(b) resulted in an arbitration award or civil judgment against you, regardless of amount, or;
(c) was settled for an amount of $10,000 or more?
(2)
Have you ever been the subject of an
investment-related
, consumer-initiated complaint, not otherwise
reported under question 14I(1) above, which alleged that you were involved in one or more sales practice
violations
, and which complaint was settled for an amount of $10,000 or more?
(3)
Within the past twenty four (24) months, have you been the subject of an investment-related,
consumer-initiated, written complaint, not otherwise reported under question 14I(1) or (2) above, which:
(a) alleged that you were involved in one or more sales practice violations and contained a claim for
compensatory damages of $5,000 or more (if no damage amount is alleged, the complaint must be
reported unless the firm has made a good faith determination that the damages from the alleged conduct
would be less than $5,000), or;
(b)
alleged that you were involved in forgery, theft, misappropriation or conversion of funds or securities?
Termination Disclosure
14J. Have you ever voluntarily
resigned
, been discharged or permitted to
resign
after allegations were made
that accused you of:
(1) violating investment-related statutes, regulations, rules, or industry standards of conduct?
(2) fraud or the wrongful taking of property?
(3)
failure to supervise in connection with investment-related statutes, regulations, rules or industry standards of
conduct?
Financial Disclosure
14K.
14L.
14M.
Within the past 10 years:
(1) have you made a compromise with creditors, filed a bankruptcy petition or been the subject of an
involuntary bankruptcy petition?
(2) based upon events that occurred while you exercised control over it, has an organization made a
compromise with creditors, filed a bankruptcy petition or been the subject of an involuntary bankruptcy
(3)
based upon events that occurred while you exercised control over it, has a broker or dealer been the
subject of an involuntary bankruptcy petition, or had a trustee appointed, or had a direct payment
procedure initiated under the Securities Investor Protection Act?
Has a bonding company ever denied, paid out on, or revoked a bond for you?
Do you have any unsatisfied judgments or liens against you?
Page 12 of 28
_
______________________________________
_
______________________________________
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
Please Read Carefully. All signatures required on this Form U4 filing must be made in this section.
A "signature" includes a manual signature or an electronically transmitted equivalent. For purposes of an electronic form filing, a signature is effected by typing a name in the designated
signature field. By typing a name in this field, the signatory acknowledges and represents that the entry constitutes in every way, use, or aspect, his or her legally binding signature.
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGMENT AND CONSENT This section must be completed on all initial or Temporary Registration form filings.
15B. FIRM/APPROPRIATE SIGNATORY REPRESENTATIONS This section must be completed on all initial or Temporary Registration form filings.
15C. TEMPORARY REGISTRATION ACKNOWLEDGMENT This section must be completed on Temporary Registration form filings to be able to receive Temporary Registration.
15D. INDIVIDUAL/APPLICANT'S AMENDMENT ACKNOWLEDGMENT AND CONSENT This section must be completed on any amendment filing that amends any information in
Section 14 (Disclosure Questions) or any Disclosure Reporting Page (DRP).
15E. FIRM/APPROPRIATE SIGNATORY AMENDMENT REPRESENTATIONS This section must be completed on all amendment form filings.
15F. FIRM/APPROPRIATE SIGNATORY CONCURRENCE This section must be completed to concur with a U4 filing made by another firm (IA/BD) on behalf of an individual that is also
registered with that other firm (IA/BD).
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGEMENT AND CONSENT
15. SIGNATURES
1. I swear or affirm that I have read and understand the items and instructions on this form
and that my answers (including attachments) are true and complete to the best of my
knowledge. I understand that I am subject to administrative, civil or criminal penalties if I give
false or misleading answers.
2. I apply for registration with the jurisdictions and SROs indicated in Section 4 (SRO
REGISTRATION) and Section 5 (JURISDICTION REGISTRATION) as may be amended
from time to time and, in consideration of the jurisdictions and SROs receiving and
considering my application, I submit to the authority of the jurisdictions and SROs and agree
to comply with all provisions, conditions and covenants of the statutes, constitutions,
certificates of incorporation, by-laws and rules and regulations of the jurisdictions and SROs
as they are or may be adopted, or amended from time to time. I further agree to be subject
to and comply with all requirements, rulings, orders, directives and decisions of, and
penalties, prohibitions and limitations imposed by the jurisdictions and SROs, subject to right
of appeal or review as provided by law.
3. I agree that neither the jurisdictions or SROs nor any person acting on their behalf shall
be liable to me for action taken or omitted to be taken in official capacity or in the scope of
employment, except as otherwise provided in the statutes, constitutions, certificates of
incorporation, by-laws or the rules and regulations of the jurisdictions and SROs.
4. I authorize the jurisdictions, SROs, and the designated entity to give any information they
may have concerning me to any employer or prospective employer, any federal, state or
municipal agency, or any other SRO and I release the jurisdictions, SROs, and the
designated entity, and any person acting on their behalf from any and all liability of whatever
nature by reason of furnishing such information.
5. I agree to arbitrate any dispute, claim or controversy that may arise between me and my
firm, or a customer, or any other person, that is required to be arbitrated under the rules,
constitutions, or by-laws of the SROs indicated in Section 4 (SRO REGISTRATION) as may
be amended from time to time and that any arbitration award rendered against me may be
entered as a judgment in any court of competent jurisdiction.
6. For the purpose of complying with the laws relating to the offer or sale of securities or
commodities or investment advisory activities, I irrevocably appoint the administrator of each
j
urisdiction indicated in Section 5 (JURISDICTION REGISTRATION) as may be amended
from time to time, or such other person designated by law, and the successors in such office,
my attorney upon whom may be served any notice, process, pleading, subpoena or other
document in any action or proceeding against me arising out of or in connection with the
offer or sale of securities or commodities, or investment advisory activities or out of the
violation or alleged violation of the laws of such jurisdictions. I consent that any such action
or proceeding against me may be commenced in any court of competent jurisdiction and
proper venue by service of process upon the appointee as if I were a resident of, and had
been lawfully served with process in the jurisdiction. I request that a copy of any notice,
process, pleading, subpoena or other document served hereunder be mailed to my current
residential address as reflected in this form or any amendment thereto.
7. I consent that the service of any process, pleading, subpoena, or other document in any
investigation or administrative proceeding conducted by the SEC, CFTC or a jurisdiction or in
any civil action in which the SEC, CFTC or a jurisdiction are plaintiffs, or the notice of any
investigation or proceeding by any SRO against the applicant, may be made by personal
service or by regular, registered or certified mail or confirmed telegram to me at my most
recent business or home address as reflected in this Form U4, or any amendment thereto,
by leaving such documents or notice at such address, or by any other legally permissible
means. I further stipulate and agree that any civil action or administrative proceeding
instituted by the SEC, CFTC or a jurisdiction may be commenced by the service of process
as described herein, and that service of an administrative subpoena shall be effected by
such service, and that service as aforesaid shall be taken and held in all courts and
administrative tribunals to be valid and binding as if personal service thereof had been
made.
8.
I authorize all my employers and any other person to furnish to any jurisdiction, SRO,
designated entity, employer, prospective employer, or any agent acting on its behalf, any
information they have, including without limitation my creditworthiness, character, ability,
business activities, educational background, general reputation, history of my employment
and, in the case of former employers, complete reasons for my termination. Moreover, I
release each employer, former employer and each other person from any and all liability, of
whatever nature, by reason of furnishing any of the above information, including that
information reported on the Uniform Termination Notice for Securities Industry Registration
(Form U5). I recognize that I may be the subject of an investigative consumer report and
waive any requirement of notification with respect to any investigative consumer report
ordered by any jurisdiction, SRO, designated entity, employer, or prospective employer. I
understand that I have the right to request complete and accurate disclosure by the
j
urisdiction, SRO, designated entit
y
, employer or prospective employer of the nature and
scope of the requested investigative consumer report.
9. I understand and certify that the representations in this form apply to all employers with
whom I seek registration as indicated in Section 1 (GENERAL INFORMATION) or Section
6 (REGISTRATION REQUESTS WITH AFFILIATED FIRMS) of this form. I agree to
update this form by causing an amendment to be filed on a timely basis whenever changes
occur to answers previously reported. Further, I represent that, to the extent any
information previously submitted is not amended, the information provided in this form is
currently accurate and complete.
10. I authorize any employer or prospective employer to file electronically on my behalf
any information required in this form or any amendment thereto; I certify that I have
reviewed and approved the information to be submitted to any jurisdiction or SRO on this
Form U4 Application; I agree that I will review and approve all disclosure information that
will be filed electronically on my behalf; I further agree to waive any objection to the
admissibility of the electronically filed records in any criminal, civil, or administrative
p
roceeding.
A
pplicant or applicant's agent has typed applicant's name under this section to attest to the
completeness and accuracy of this record. The applicant recognizes that this typed name
constitutes, in every way, use or aspect, his or her legally binding signature.
Date (MM/DD/YYYY)
_____________________________
Si
g
nature of
App
licant
Printed Name
Page 13 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
THE FIRM MUST COMPLETE THE FOLLOWING:
To the best of my knowledge and belief, the applicant is currently bonded where required, and, at the time of approval, will be familiar with the statutes, constitution(s), rules and by-laws
of the agency, jurisdiction or SRO with which this application is being filed, and the rules governing registered persons, and will be fully qualified for the position for which application is
being made herein. I agree that, notwithstanding the approval of such agency, jurisdiction or SRO which hereby is requested, I will not employ the applicant in the capacity stated herein
without first receiving the approval of any authority that may be required by law.
This firm has communicated with all of the applicant's previous employers for the past three years and has documentation on file with the names of the persons contacted and the date of
contact. In addition, I have taken appropriate steps to verify the accuracy and completeness of the information contained in and with this application.
I have provided the applicant an opportunity to review the information contained herein and the applicant has approved this information and signed the Form U4.
_
______________________________________
Printed Name
_
______________________________________
Date
(
MM
/
DD
/
YYYY
)
_
______________________________________
Signature of
Appropriate Signatory
15C. TEMPORARY REGISTRATION ACKNOWLEDGEMENT
15B. FIRM/APPROPRIATE SIGNATORY REPRESENTATIONS
If an applicant has been registered in a jurisdiction or self regulatory organization (SRO) in the 30 days prior to the date an application for
registration is filed with the Central Registration Depository or Investment Adviser Registration Depository, he or she may qualify for a
Temporary Registration to conduct securities business in that jurisdiction or SRO if this acknowledgment is executed and filed with the Form
U4 at the applicant's firm.
This acknowledgment must be signed only if the applicant intends to apply for a Temporary Registration while the application for registration
is under review.
I request a Temporary Registration in each jurisdiction and/or SRO requested on this Form U4, while my registration with the jurisdiction(s)
and/or SRO(s) requested is under review;
I am requesting a Temporary Registration with the firm filing on my behalf for the jurisdiction(s) and/or SRO(s) noted in Section 4 (SRO
REGISTRATION) and/or Section 5 (JURISDICTION REGISTRATION) of this Form U4;
I understand that I may request a Temporary Registration only in those jurisdiction(s) and/or SRO(s) in which I have been registered with my
prior firm within the previous 30 days;
I understand that I may not engage in any securities activities requiring registration in a jurisdiction and/or SRO until I have received notice
from the CRD or IARD that I have been granted a Temporary Registration in that jurisdiction and/or SRO;
I agree that until the Temporary Registration has been replaced by a registration, any jurisdiction and/or SRO in which I have applied for
registration may withdraw the Temporary Registration;
If a jurisdiction or SRO withdraws my Temporary Registration, my application will then be held pending in that jurisdiction and/or SRO until its
review is complete and the registration is granted or denied, or the application is withdrawn;
I understand and agree that, in the event my Temporary Registration is withdrawn by a jurisdiction and/or SRO, I must immediately cease
any securities activities requiring a registration in that jurisdiction and/or SRO until it grants my registration;
I understand that by executing this Acknowledgment I am agreeing not to challenge the withdrawal of a Temporary Registration; however, I
do not waive any right I may have in any jurisdiction and/or SRO with respect to any decision by that
jurisdiction and/or SRO to deny my
application for registration.
_
______________________________________
Date (MM/DD/YYYY)
_
__________________________________________________________________
Printed Name
_
______________________________________________________
Signature of
Applicant
15D. AMENDMENT INDIVIDUAL/APPLICANT'S ACKNOWLEDGEMENT AND CONSENT
_
______________________________________
Date (MM/DD/YYYY)
_
_______________________________________________________________
Signature of
Applicant
_
____________________________________________________________________
_
Printed Name
Page 14 of 28
_
______________________________________
_
_______________________________________________________________
_
____________________________________________________________________
_
_
______________________________________
_
_______________________________________________________________
_
___________________________________________________________________
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
THE FIRM MUST COMPLETE THE FOLLOWING:
Date (MM/DD/YYYY) Signature of Appropriate Signatory
Printed Name
15F. FIRM/APPROPRIATE SIGNATORY CONCURRENCE
By typing an appropriate signatory's name in this field, I swear or affirm that I have reviewed and that I concur with this filing:
Date (MM/DD/YYYY) Signature of
Appropriate Signatory
Printed Name
15E. FIRM/APPROPRIATE SIGNATORY AMENDMENT REPRESENTATIONS
Page 15 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
ATTACHMENT SHEET
Use this attachment to report continued information.
A
NSWER
SECTION NUMBER
Page 16 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
DISCLOSURE REPORTING PAGES
U4 - BANKRUPTCY/SIPC/COMPROMISE WITH CREDITORS DRP
If events result in affirmative answers to both 14K(1) and 14K(2), details to each must be provided on separate DRPs.
1. Action Type:________________________________
2. Action Date (MM/DD/YYYY) (Provide date bankruptcy was filed, or date SIPC was
Exact Explanation
initiated, or date of compromise with creditor):_____________________________
If not exact, provide explanation:
3. If the financial action relates to an organization over which you exercise(d) control, enter organization name and your position, title or
relationship:
Was the organization investment-related?
Y
es No
4. Court action brought in (Name of Federal, State or Foreign Court), Location of Court (City or County and State or Country), Docket/Case
Number and Bankruptcy Chapter Number (if Federal Bankruptcy Filing):
5. Is action currently pending?
Y
es No
6. If not pending, provide Disposition Type:_____________________________________________
7. Disposition Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
8. Provide a brief summary of events leading to the action and if not discharged, explain. (Your information must fit within the space
provided.):
9. If a SIPA trustee was appointed or a direct payment procedure was begun, enter the amount paid or agreed to be paid by you; or the
name of the trustee:
Currently Open?
Y
es No
Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY):_________________________
Exact
Explanation
If not exact, provide explanation:
This Disclosure Reporting Page is an
INITIAL OR AMENDED
response to report details for affirmative responses to
Questions 14K(1), 14K(2), and 14K(3) on Form U4;
Check question(s) you are responding to: 14K(1) 14K(2) 14K(3)
10. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the
current status or final disposition. Your information must fit within the space provided.
Page 17 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - BOND DRP
This Disclosure Reporting Page is an
AMENDED
response to report details for affirmative response to
INITIAL OR
Question 14L on Form U4;
Check question you are responding to: 14L
If multiple, unrelated events result in the same affirmative answer, details must be provided on separate DRPs.
1. Firm Name: (Policy Holder) _________________________________________________________
2. Bonding Company Name: __________________________________________________________
3. Disposition Type: __________________________________________________________
4. Disposition Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
5. If disposition resulted in Payout, list Payout Amount and Date Paid:
6. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the
current status or final disposition. Your information must fit within the space provided.
Page 18 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
This Disclosure Reporting Page is an
Question 14H on Form U4;
INITIAL OR AMENDED
response to report details for affirmative response to
Check question(s) you are responding to:
14H(1)(a) 14H(1)(b) 14H(1)(c) 14H(2)
10. If Pending, date notice/process was served (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
Page 19 of 28
U4 - CIVIL JUDICIAL DRP
One event may result in more than one affirmative answer to the above items. Use only one DRP to report details to the same event.
Unrelated civil judicial actions must be reported on separate DRPs.
1. Court Action intiated by: (Name of regulator, foreign financial regulatory authority, SRO, commodities exchange, Agency, Firm, Private
Plaintiff, etc.)
2. Principal Relief Sought:_________________________________________________
Other Relief Sought:
3. Filing Date of Court Action (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
4. Principal Product Type:_________________________________________________
Other Product Types:
5. Formal Action was brought in (include name of Federal, Military, State or Foreign Court, Location of Court - City or County and State or
Country, Docket/Case Number):
6. Employing Firm when activity occurred which led to the civil judicial action:________________________________________________
7. Describe the allegations related to this civil action. (Your information must fit within the space provided.):
8. Current Status?
Pending On Appeal Final
9. If on appeal, action appealed to (provide name of court): Date Appeal Filed (MM/DD/YYYY):
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - CIVIL JUDICIAL DRP (CONTINUED)
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only.
11. How was matter resolved:___________________________________________________
12. Resolution Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
13. Resolution Detail:
A
. Were any of the following Sanctions Ordered or Relief Granted? (Check appropriate items):
Monetary/Fine
A
mount: $______________________
Disgorgement/Restitution
Revocation/Expulsion/Denial
Bar
Censure Cease and Desist/Injunction Suspension
B. Other Sanctions:
C.
Sanction detail: if suspended, enjoined or barred, provide duration including start date and capacities affected (General Securities
Principal, Financial Operations Principal, etc.). If requalification by exam/retraining was a condition of the sanction, provide length of
time given to requalify/retrain, type of exam required and whether condition has been satisfied. If disposition resulted in a fine,
penalty, restitution, disgorgement or monetary compensation, provide total amount, portion levied against you, date paid and if any
portion of penalty was waived:
14. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action, as well as the
current status or disposition and/or finding(s). Your information must fit within the space provided.
Page 20 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
This Disclosure Reporting Page is an
14A and 14B on Form U4;
INITIAL OR AMENDED
response to report details for affirmative responses to Questions
Check question(s) you are responding to:
14A(1)(a) 14A(1)(b) 14A(2)(a) 14A(2)(b) 14B(1)(a) 14B(1)(b) 14B(2)(a) 14B(2)(b)
5. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the charge(s) as well as the
current status or final disposition. Your information must fit within the space provided.
Page 21 of 28
U4 - CRIMINAL DRP
Use this DRP to report all charges arising out of the same event. One event may result in more than one affirmative answer to the above
items. Multiple counts of the same charge arising out of the same event should be reported on the same DRP. Unrelated criminal actions,
including separate cases arising out of the same event, must be reported on separate DRPs.
Applicable court documents (i.e., criminal complaint, information or indictment as well as judgment of conviction or sentencing
documents) must be provided to the CRD if not previously submitted.
1. If charge(s) were brought against an organization over which you exercise(d) control: Enter Organization Name, whether or not the
organizaton was an investment-related business and your position, title or relationship.
2. Formal Charge(s) were brought in: (include name of Federal, Military, State or Foreign Court, Location of Court - City or County and
State or Country, Docket/Case number).
3.
Event Disclosure Detail
(Use this for both organizational and individual charges.)
A
. Date First Charged (MM/DD/YYYY):___________________________
Exact Explanation
If not exact, provide explanation:
B. Event Disclosure Detail (include Charge(s)/Charge Description(s), and for each charge provide: 1. number of counts,
2
.
felony
or
misdemeanor
, 3. plea for each charge, and 4. product type if charge is
investment-related
):
C. Did any of the Charge(s) within the Event involve a Felony?
Y
es No
D. Current status of the Event?
Pending On Appeal Final
E. Event Status Date (complete unless status is Pending) (MM/DD/YYYY):_________________
Exact Explanation
If not exact, provide explanation:
4. Disposition Disclosure Detail
Include for each charge, A. Disposition Type [e.g., convicted, acquitted, dismissed, pretrial, etc.], B. Date, C. Sentence/Penalty,
D. Duration [if sentence - suspension, probation, etc.], E. Start Date of Penalty, F. Penalty/Fine Amount and G. Date Paid.
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - CUSTOMER COMPLAINT
/
A
RBITRATION
/
CIVIL LITIGATION DRP
This Disclosure Reporting Page is an
AMENDED
response to report details for affirmative response to
Question 14I on Form U4;
INITIAL OR
Check question(s) you are responding to:
14I(1)(a) 14I(1)(b) 14I(1)(c) 14I(2) 14I(3)(a) 14I(3)(b)
One event may result in more than one affirmative answer to the above items. Use only one DRP to report details related to one customer
complaint/arbitration/civil litigation. Use a separate DRP for each customer complaint/arbitration/civil litigation.
DRP Instructions:
- In all matters (i.e., customer complaints, arbitrations/CFTC reparations, civil litigations), complete items 1-6.
- If the matter involves only a customer complaint, also complete items 7-12, as appropriate.
- If the customer complaint has evolved into an arbitration/CFTC reparation or civil litigation, amend the existing DRP by completing
items 9 and 10.
- If the matter involves an arbitration or CFTC reparation, complete items 13-19, as appropriate.
- If the matter involves a civil litigation, complete items 20-27.
- Item 28 is an optional field and applies to all event types (i.e., customer complaint, arbitration/CFTC reparation, civil litigation).
Complete items 1-6 for all events.
1. Customer Name(s):
2. Customer(s) State of Residence:______________________________________
Other state(s) of residence/detail:
3. Employing Firm when activities occurred which led to the complaint:____________________________________________________
4. Allegation(s) and a brief summary of events related to the allegation(s) including dates when activities leading to the allegation(s)
occurred:
5. Principal Product Type: _________________________________ Other Product Types:
6. Alleged Compensatory Damage Amount: $_________________________________
If the matter involves only a customer complaint, complete items 7-12 as appropriate.
7. Date customer complaint was received (MM/DD/YYYY): ________________________________
Exact Explanation
If not exact, provide explanation:
8. Is the customer complaint pending?
Yes No
If the customer complaint has evolved into an arbitration/CFTC reparation or civil litigation, amend the existing DRP by completing
items 9 and 10.
9. If the customer complaint is not pending, provide status:
If status is settlement, complete items 11 and 12;
If status is arbitration/reparation, complete items 13-19;
If status is litigation, complete items 20-27.
Arbitration/Reparation
Litigation
Closed/No Action Withdrawn Denied Settled
10. Status Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
Page 22 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
28. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the customer complaint,
arbitration/CFTC reparation and/or civil litigation as well as the current status or final disposition(s). Your information must fit within
the space provided.
Page 23 of 28
U4 - CUSTOMER COMPLAINT/ARBITRATION/CIVIL LITIGATION DRP (CONTINUED)
11. Settlement Amount (if settled without arbitration, litigation or reparation): $________________________________
12. Individual Contribution Amount: $________________________________
If the matter involves an arbitration or CFTC reparation, complete items 13-19, as appropriate.
13. Arbitration/Reparation claim filed with (NASD, AAA, NYSE, CBOE, CFTC, etc.) and Docket/Case Number:
14. Date notice/process was served (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
15. Is arbitration/reparation pending?
Yes No
16. If the arbitration/reparation is not pending, what was the disposition?:________________________________
17. Disposition Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
18. Amount of Monetary Compensation (award, settlement, reparation amount): $________________________________
19. Individual Contribution Amount: $________________________________
If the matter involves a civil litigation, complete items 20-27.
20. Court that case was filed in (include name of Federal, Military, State or Foreign Court, Location of Court - City or County and State or
Country, Docket/Case number).
21. Date notice/process was served (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
22. Is the civil litigation pending?
Yes No
23. If the civil litigation is not pending, what was the disposition?________________________________
24. Disposition Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
25. Amount of Monetary Compensation (judgment, restitution, settlement amount): $________________________________
26. Individual Contribution Amount: $________________________________
27. If the action is currently on appeal enter date appeal filed (MM/DD/YYYY):_________________________
Exact Explanation
If not exact, provide explanation:
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
This Disclosure Reporting Page is an
INITIAL OR AMENDED
response to report details for affirmative response to
Question 14G(2)
on Form U4;
Check question you are responding to: 14G(2)
Complete this DRP only if you are answering "yes" to Item 14G(2). If you answered "yes" to Item 14G(1), complete the Regulatory Action
DRP. If you have been notified that the investigation has been concluded without formal action, complete items 1, 2, 3 and 4 of this DRP to
update. One event may result in more than one investigation. If more than one authority is investigating you, use a separate DRP to provide
details.
1. Notice Received From: (Name of Regulator, Agency, SRO, etc. initiating the investigation):____________________________________
2. Notice Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
3. Describe briefly the nature of the investigation, if known, or details of the resolution. (Your information must fit within the space provided.):
U4 - INVESTIGATION DRP
4. Date Resolved (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
Page 24 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - JUDGMENT/LIEN DRP
This Disclosure Reporting Page is an
INITIAL OR AMENDED
response to report details for affirmative response to
Question 14M
on Form U4;
Check question you are responding to: 14M
If multiple, unrelated events result in the same affirmative answer, details must be provided on separate DRPs.
1. Judgment/Lien Amount:_____________________________________
2. Judgment/Lien Holder:_____________________________________
3. Judgment/Lien Type:_____________________________________
4. Date Filed (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
5. Is Judgment/Lien outstanding?
Y
es No
If No, provide status date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
If No, how was matter resolved?
6. Court (Name of Federal, State or Foreign Court), Location of Court (City or County and State or Country) and Docket/Case Number:
7. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the current
status or final disposition. Your information must fit within the space provided.
Page 25 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - REGULATORY ACTION DRP
This Disclosure Reporting Page is an
AMENDED
response to report details for affirmative responses to
INITIAL OR
Questions 14C, 14D, 14E, 14F and 14G(1) on Form U4;
Check question(s) you are responding to:
14C(1) 14C(2) 14C(3) 14C(4) 14C(5) 14D(1)(a) 14D(1)(b) 14D(1)(c)
14D(1)(d) 14D(1)(e) 14D(2)(a) 14D(2)(b) 14E(1) 14E(2) 14E(3) 14E(4)
14F 14G(1)
One event may result in more than one affirmative answer within each of the above items. Use only one DRP to report details to the same
event. If an event gives rise to actions by more than one regulator, provide details to each action on a separate DRP.
1. Regulatory Action initiated by:
SEC Other Federal State SRO Foreign
Other
Federal Banking Agency National Credit Union Administration
(Full name of regulator, foreign financial regulatory authority, Federal, State, SRO, commodities exchange or National Credit Union
A
dministration)
2. Principal Sanction:_________________________________________________
Other Sanctions:
3.
Date Initiated (MM/DD/YYYY):
_
_______________________________
Exact Explanation
If not exact, provide explanation:
4.
Docket/Case Number:
_
_______________________________________________
5. Employing Firm when activity occurred which led to the regulatory action:________________________________________________
6. Principal Product Type:_________________________________________________
Other Product Types:
7. Describe the allegations related to this regulatory action. (Your information must fit within the space provided.):
8. Current status?
Pending On Appeal Final
9. If on appeal, regulatory action appealed to: (SEC, SRO, Federal or State Court) and Date Appeal Filed:
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only.
10.
How was the matter resolved:
_
_____________________________________________________________________________
11. Resolution Date (MM/DD/YYYY):
_
_______________________________
Exact Explanation
If not exact, provide explanation:
12. Resolution Detail:
A
. Were any of the following sanctions ordered? (Check all appropriate items):
Monetary/Fine
A
mount: $______________________
Revocation/Expulsion/Denial Disgorgement/Restitution
Censure Cease and Desist/Injunction Bar Suspension
B. Other sanctions ordered:
Page 26 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - REGULATORY ACTION DRP (CONTINUED)
C. Sanction detail: if suspended, enjoined or barred, provide duration including start date and capacities affected (General Securities
Principal, Financial Operations Principal, etc.). If requalification by exam/retraining was a condition of the sanction, provide length of
time given to requalify/retrain, type of exam required and whether condition has been satisfied. If disposition resulted in a fine, penalty,
restitution, disgorgement or monetary compensation, provide total amount, portion levied against you, date paid and if any portion of
penalty was waived:
13.
Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the current
status or disposition and/or finding(s). Your information must fit within the space provided.
Page 27 of 28
Rev. Form U4 (10/2005)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
INDIVIDUAL NAME:
INDIVIDUAL CRD #:
SSN:
FIRM CRD #:
U4 - TERMINATION DRP
This Disclosure Reporting Page is an
AMENDED
response to report details for affirmative response to
Question 14J on Form U4;
INITIAL OR
Check question(s) you are responding to: 14J(1) 14J(2) 14J(3)
One event may result in more than one affirmative answer to the above items. Use only one DRP to report details related to the same
termination. Use a separate DRP for each termination reported.
1. Firm Name:__________________________________________________________________
2. Termination Type:__________________________________________________________
3. Termination Date (MM/DD/YYYY):________________________________
Exact Explanation
If not exact, provide explanation:
4. Allegation(s):
5. Principal Product Type:_____________________________________ Other Product Types:
6. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the termination.
Your information must fit within the space provided.
Page 28 of 28
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Form U4: Securities Industry Uniform Application Registration or (California)

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Completed 1 February 2022

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