Application For Registration As Broker-Dealer Of Securities {FCN154}

FCN 2-2-154 Approved 10-1-87 INSURANCE, SECURITIES, BANKING & REAL ESTATE BRANCH Dept. of Revenue & Taxation Government of Guam Agana, Guam 96910 APPLICATION FOR REGISTRATION AS BROKER-DEALER OF SECURITIES (Filing Fee $25.00) The undersigned, an applicant for registration as a broker-deale r of securities, submits the following infor- mation to the Administrator of Securities as required by Sectio n 45202, Uniform Securities Act of Guam. 1. Name, residence address, and business address of the applic ant. 2. Name under which business is conducted. 3. Check one only. Type of Firm: ( ) Corporation ( ) Partnership ( ) Sole Proprietorship ( ) Other 4. Names, residence and business addresses of all persons inte rested in the business as principals, partners, officers or directors, giving the title of each. 5. The general plan and character of business. 6. Length of time engaged in securities business as a broker- dealer. 7. States in which applicant is registered as a broker-dealer. 8. Stock or bond exchange, if any, of which applicant is a member. 9. Has an application for registration as an investment advise r or agent or broker-dealer ever been refused, revoked, suspended in any State or Territory or by the Securit ies and Exchange Commission? If so, attach a complete statement of facts in respect thereto. 10. Has any person interested in the business as principal, pa rtner, officer or director ever been con- victed of a violation of a criminal statute? If so, attach a complete statement of facts in respect thereto. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 11. Names, official titles, and residence addresses of individu als who were registered as agents of the Applicant. 12. Experience of the individuals designated in Question 11 ab ove, giving names of employers, business ad- dresses, and dates of employment. 13. There shall be filed an irrevocable written consent to se rvice of process on the Administrator of Securities as provided by Section 45414 (g), Chapter 4, Title 41, Gover nment Code of Guam. 14. Current Financial Statement must be attached to this Appli cation. (Applicant) Territory of Guam ) ) SS. City of Agana ) Being first duly sworn on oath deposes and says that he is the of the applicant named in the foregoing application; that he is aut horized to make this verification for and on behalf of said ; that he has read the application and all the exhibits, stateme nts, and documents attached thereto; that theinformation contained in the application, exhibits, statements an d documents is true to the best of his informa-tion, knowledge and belief. Subscribed and sworn to before me this day of , 19 Notary Public in and for the Territory of Guam. My Commission expires: American LegalNet, Inc. www.USCourtForms.com