Dealer Questionnaire And Affidavit Prior Sales {COM 4523}

Licensing Section 77 South High Street 22 nd Floor Columbus, Ohio 43215 Com 4523 3/ 20 /19 An Equal Opportunity Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov DEALER QUESTIONAIRE AND AFFIDAVIT : PRIOR SALES Date: Full Name of Dealer: Firm CRD No.: The undersigned authorized signatory certifies as follows: I have conducted a thorough review into the activities of the Dealer listed above, and, to the best of my knowledge within the past 60 months, the Dealer has not effected any non - exempt transactio ns in the State of Ohio. If any transactions were made in the past 60 months in reliance upon an exemption, I have attached a list of those transactions. As to those transactions, I have identified the exemption upon which the Dealer relied and provided an explanation. For those transactions that occurred within the past 60 months that were effected without the benefit of an exemption, I am providing the following information: Name of the security; Date and amount of the trade, including the commission paid to the Dealer and to the Agent; and The Agent who effected the transaction. I am aware that the State of Ohio may verify this information with my clearing firm. I further certify that the Deal er listed above will refrain from transacting business as a Dealer in Ohio until registration is completed. I acknowledge that if my response to any of the above is false or if the Dealer transacts business during the period prior to licensure, the Dealer and I are subject to sanctions pursuant to the laws of Ohio. Name of Authorized Signatory (Please Print) Signature of Authorized Signatory Subscribed and sworn befo re me this day of , 2 . County of , State of . My commission expires . Notary Public Signature American LegalNet, Inc. www.FormsWorkFlow.com