Application For Renewal Of A Broker-Dealers Registration {S.A. 2}

S.A.2 (Rev. 7/99) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING APPLICATION FOR RENEWAL OF A BROKER-DEALERS REGISTRATION 1. Name of Applicant:_________________________________________________________. 2. Principal Address of Applicant: ________________________________________ ________. 3. Attach the most current audited financial statements of the broker-deale r prepared and certified by an independent certified public accountant (if they have n ot been previously submitted). If the statements are not dated within 120 days of the fil ing of the application, financial statements attested to by an officer of the firm or the latest quarterly FOCUS report must also be submitted. The financial statements or FOCUS report must be dated within the 120 day period. The financial statements should include all reports, sc hedules and statements defined in 21 VAC 5-20-30 B 2. 4. During the last twelve months, has there been any change in the organiza tion or policy of the applicant, including form of organization, officers, partners, manag ers, business address, changes which would cause affirmative answers to any part of qu estion 10 of form BD, etc.? ____. If we have not had prior notification of such change(s ), attach appropriate amended page(s) to form BD. 5. The application must be accompanied by a fee of $200 payable to the Trea surer of Virginia. If the renewal is not granted, the fee is not refundable. ______________________________________________________ Broker-Dealer Date ______________________________________________________ By (Signature) Title COMMONWEALTH OF VIRGINIA _________________OF__________________, to-wit: _____________________________________, being first duly sworn, deposes and says: I have been authorized by the applicant to execute and file the foregoin g application. I have read the application and exhibits filed with it, and the facts stated in the application and in the exhibits are true to the best of my knowledge, information and belie f. _________________________________________________________ Affiant Subscribed and sworn to before me this _________ day of ___________ _____. _________________________________________________________ Notary Public My commission expires:______________________________ (SEAL) NOTE: NON-NASD MEMBER FIRMS SHOULD ALSO ATTACH TO THIS APPLICATION S.D.4.A AND, IF APPLICABLE, S.D.4.B AND S.D.4.C. A $30 FEE FOR EACH AGENT LISTE D ON FORM S.D.4.A AND A $200 RENEWAL FEE FOR THE FIRM SHOULD BE INCORPORATED INTO ONE CHECK, PAYABLE TO THE TREASURER OF VIRGINIA. American LegalNet, Inc. www.USCourtForms.com