Uniform Branch Office Registration Form {BR}

Rev. Form BR (10/2005) UNIFORM BRANCH OFFICE REGISTRATION FORM FIRM NAME: CRD #: 1. GENERAL INFORMATION WARNING: Failure to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep accurate books and records or otherwise to comply with the provisions of law applying to the conduct of business as a broker-dealer or investment adviser would violate the federal securities laws, self-regulatory organization rules, and the laws of the jurisdictions, and may result in disciplinary, administrative, injunctive, or criminal action. Applicant CRD#: Name and principal place of business of firm filing this form: Applicant Name: Address Street 1: Address Street 2: City: State: Country: Postal Code: Firm Billing Code (Firm Branch Designation): NYSE Branch Code Number: CRD Branch Number: Branch Office Location: Branch Address Street 1: Branch Address Street 2: City: State: Country: Postal Code: By filing this amendment to relocate this branch from, and/or to, a state that requires registration or notice filing of branch offices, applicant acknowledges that it is closing the branch in ____________________ [and requesting branch registration or notice filing in ____________________ ]. Private Residence Check Box: If this address is a private residence, check this box. Branch Telephone Number: Branch Facsimile Number: Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form BR (10/2005) UNIFORM BRANCH OFFICE REGISTRATION FORM FIRM NAME: CRD #: 2. REGISTRATION/NOTICE FILING/TYPE OF OFFICE Register/Notice File Branch with SRO/Jurisdiction: NASD NYSE Jurisdiction: By filing an amendment to relocate this branch to another state, applicant acknowledges that submission of this amendment closes this branch in ____________________ [and requests branch registration in ____________________ ] [and requests notice filing in ____________________ ]. By unchecking NYSE registration and checking this box, applicant attests that it is not required under NYSE rules to register this branch location with the NYSE. Type of Branch Office Registration: Broker-Dealer Investment Adviser Yes No Is this an NASD Office of Supervisory Jurisdiction (OSJ)?: If not, indicate the CRD branch number, or firm billing code, for the OSJ that has supervisory responsibility for this branch, and the CRD Number of the supervisor in charge of that OSJ: CRD Branch Number: Firm Billing Code (Firm Branch Designation): OSJ Supervisor CRD Number: NYSE Type of Office: Small Branch Regular Branch If this is an NYSE Small Branch, indicate the CRD branch number, NYSE branch code number or firm billing code of the location from which this branch is supervised, and the supervisor's CRD number: CRD Branch Number: NYSE Branch Code Number: Firm Billing Code (Firm Branch Designation): Supervisor CRD Number: Enter the name and/or CRD# of each supervisor(s)/person(s)-in-charge: Name: CRD Number: Person-In-Charge Supervisor Name: CRD Number: Person-In-Charge Supervisor Name: CRD Number: Person-In-Charge Supervisor Delete Delete Delete Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form BR (10/2005) UNIFORM BRANCH OFFICE REGISTRATION FORM FIRM NAME: CRD #: 3. TYPES OF ACTIVITIES/OTHER BUSINESS NAMES/WEBSITES Indicate the types of financial industry activities conducted by the applicant at this branch (Check all that apply): Sales Investment Advisory Services Investment Banking Research Market Making Back Office Operations Underwriting Does any associated person conduct, at this branch, investment-related activities in addition to the activities indicated above?: If yes, provide description: Yes No Will any associated person of this branch office conduct any investment-related activities at this branch office under any name other than those names disclosed on the applicant's Form BD or Form ADV?: Yes No If yes, provide all other business names for this location: Name: Delete Name: Delete Name: Delete Does this branch office use a website other than the primary website address used by the applicant?: If yes, provide the website address(es): Website Address: Delete Yes No Website Address: Delete Website Address: Delete Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form BR (10/2005) UNIFORM BRANCH OFFICE REGISTRATION FORM FIRM NAME: CRD #: 4. BRANCH OFFICE ARRANGEMENTS Does the branch office occupy or share space with or jointly market with a bank, savings bank, savings association, credit union, or other federally insured depository institution?: Yes No If yes, enter the name of the institution(s): Name: Name: Name: Is this a business location that will operate pursuant to a written agreement or contract (other than an insurance agency agreement) with the main office?: Yes No If yes, provide the name(s) of the entity(ies) and/ or person(s) with whom the agreement or contract was entered: Entity: Entity: Entity: Will the branch office have primary responsibility for decisions relating to the employment and remuneration of its registered representatives?: Yes No Yes No Does the branch office assume liability for its own expenses?: Does any person other than the applicant have responsibility, directly or indirectly, for paying the expenses of this branch office or otherwise have a financial interest in this branch office or its activities?: Yes No If yes: (1) Provide the following information for each entity or person responsible for expenses or with a financial interest: Name: Firm Individual Name: Firm Individual Name: Firm Individual (2) Provide an explanation of the expense payment/financial interest arrangement: CRD #: CRD #: CRD #: Registered: Yes Registered: Yes Registered: Yes No No EIN: No EIN: EIN: Delete Delete Delete Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form BR (10/2005) UNIFORM BRANCH OFFICE REGISTRATION FORM FIRM NAME: CRD #: 5. ASSOCIATED INDIVIDUALS Complete this section for initial filings only. List all registered individuals other than the supervisor(s)/person(s)-in-charge that will be associated with this branch: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: Individual Name: CRD #: In