Uniform Termination Notice For Securities Industry Registration {U5}

Rev. Form U5 (10/2005) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: NOTICE TO THE INDIVIDUAL WHO IS THE SUBJECT OF THIS FILING Even if you are no longer registered you continue to be subject to the jurisdiction of regulators for at least two years after your registration is terminated and may have to provide information about your activities while associated with this firm. Therefore, you must forward any residential address changes for two years following your termination date or last Form U5 amendment to: CRD Address Changes, P.O. Box 9495, Gaithersburg, MD 20898-9495. 1. GENERAL INFORMATION FIRST NAME: FIRM CRD #: INDIVIDUAL CRD #: Office of Employment Address: CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Registered Non-Registered OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: START DATE: Located At Supervised From STATE: POSTAL CODE: END DATE: MIDDLE NAME: FIRM NAME: INDIVIDUAL SSN: Individual NFA#: LAST NAME: SUFFIX: FIRM NFA#: FIRM Billing Code: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Registered Non-Registered OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: START DATE: Located At Supervised From STATE: POSTAL CODE: END DATE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Registered Non-Registered OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: START DATE: Located At Supervised From STATE: POSTAL CODE: END DATE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. 2. CURRENT RESIDENTIAL ADDRESS NOTICE TO THE FIRM: This is the last reported residential address. If this is not current, please enter the current residential address. ADDRESS STREET 1: ADDRESS STREET 2: FROM (MM/YYYY): TO (MM/YYYY): CITY: COUNTRY: STATE: POSTAL CODE: 3. FULL TERMINATION Is this a Full Termination? Yes No Note: A "Yes" response will terminate ALL registrations with all SROs and all jurisdictions. Reason For Termination: *Discharged *Other *Permitted to Resign Deceased Voluntary *Provide an explanation below: Page 1 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (10/2005) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 4. DATE OF TERMINATION Date Terminated (MM/DD/YYYY): _______________________________ A complete date of termination is required for full or partial termination. This date represents the actual date that the termination of registration is effective. Page 2 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (10/2005) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 5. PARTIAL TERMINATION For a partial termination, do not complete the Reason for Termination in Section 3 (FULL TERMINATION) or Section 7 (DISCLOSURE QUESTIONS). The Reason for Termination and Section 7 (DISCLOSURE QUESTIONS) should only be completed on Form U5 for full termination requests. 5A. SRO PARTIAL TERMINATION If this is a PARTIAL TERMINATION, mark the appropriate SRO registration categories to be terminated. REGISTRATION CATEGORY 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) NASD NYSE AMEX BSE NSX PCX CBOE CHX PHLX ISE Page 3 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (10/2005) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 5B. JURISDICTION PARTIAL TERMINATION Check appropriate jurisdiction(s) for broker-dealer agent (AG) and/or investment adviser representative (RA) termination. JURISDICTION Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho AG RA JURISDICTION Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri AG RA JURISDICTION Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania AG RA JURISDICTION Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia