Broker Dealer Questionnaire And Affidavit Prior Sales {BDQA}

BROKER-DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES Firm CRD No.: Date: Full Name of Broker-Dealer: SEC File No.: 8- The undersigned certifies as follows: I have conducted a thorough review into the activities of the Broker- dealer listed above and, to the best of my knowledge within the past 36 months, the firm has not effected non-exempt transactions in the state(s) indicated below. Alabama Idaho Michigan New York South Dakota Alaska Illinois Minnesota North Carolina Tennessee Arizona Indiana Mississippi North Dakota Texas Arkansas Iowa Missouri Ohio Utah California Kansas Montana Oklahoma Vermont Connecticut Kentucky Nebraska Oregon Virginia Delaware Louisiana Nevada Pennsylvania Washington District of Columbia Maine New Hampshire Puerto Rico West Virginia Florida Maryland New Jersey Rhode Island Wisconsin Georgia Massachusetts New Mexico South Carolina Wyoming Hawaii ALL If any transaction were made in reliance upon an exemption, I have attac hed a list of those transactions. As to those transactions, I have identified the exemption upon which the br oker-dealer relied and an explanation. For those transaction that occurred within the past 36 months which were effected without the benefit of an exemption. I am providing the following information: The accountholders name, address and telephone number. Name of the security. Date and amount of the trade, including the commi ssion paid to the Broker- dealer and to the Agent. The Agent who effected the transaction. I am aware that the state may verify this information with my clearing f irm. I further certify that the Broker-dealer listed above will refrain from transacting business as a Broker- Dealer in the jurisdictions shown until registration is completed. I acknowledge that if my response to any of the above is false or if the Broker-Dealer transacts business during the period prior to registration, the Broker-Dealer and I are sub ject to sanctions pursuant to the laws of the particular jurisdiction involved. Name of Principal (please print) Signature of Principal Subscribed and sworn before me this day of , . County of , State of . My commission expires . Notary Public American LegalNet, Inc. www.USCourtForms.com