Uniform Application For Securities Industry Registration Or Transfer {U-4}

Rev. FORM U-4 (03/2002) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRST NAME: MIDDLE NAME: SSN: ___-__-____ FIRM CRD #: 1. GENERAL INFORMATION LAST NAME: SUFFIX: FIRM CRD #: FIRM NAME: EMPLOYMENT DATE (MM/DD/YYYY): CRD BRANCH #: FIRM BILLING CODE: INDIVIDUAL CRD #: INDIVIDUAL SSN: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. 2. FINGERPRINT INFORMATION Electronic Filing Representation By selecting this option, I represent that I am submitting or promptly will submit to the appropriate SRO a finger printcard as required under applicable SRO rules. Fingerprint card barcode ______________________________________ Exceptions to the Fingerprint Requirement By selecting this option, I affirm that: · I have been employed continuously by the filing firm in an unregistered capacity since the last submission of a fingerprint card; or · I am exempt from the fingerprint requirement because I meet one or more of the exemptions established by Rule 17f-2 under the Securities Exchange Act of 1934. Investment Adviser Representative Only Applicants I affirm that I am applying only as an investment adviser representative and that I am not also applying or have not also applied to become a broker-dealer representative. If this radio button/box is selected, continue below. I am applying for registration only in jurisdictions that do not have fingerprint card filing requirements, or I am applying for registration in jurisdictions that have fingerprint card filing requirements and I am submitting the appropriate fingerprint card directly to the jurisdictions for processing. 3. REGISTRATION WITH UNAFFILIATED FIRMS Some jurisdictions prohibit "dual registration," which occurs when an individual chooses to maintain a concurrent registration as a representative/agent with two or more firms (either BD or IA firms) that are not affiliated. Jurisdictions that prohibit dual registration would not, for example, permit a broker-dealer agent working with brokerage firm A to maintain a registration with brokerage firm B if firms A and B are not owned or controlled by a common parent. Before seeking a dual registration status, you should consult the applicable rules or statutes of the jurisdictions with which you seek registration for prohibitions on dual registrations or any liability provisions. Please indicate whether the individual will maintain a "dual registration" status by answering the questions in this section. (Note: An individual should answer `yes' only if the individual is currently registered and is seeking registration with a firm (either BD or IA) that is not affiliated with the individual's current employing firm. If this is an initial application, an individual must answer `no' to these questions; a "dual registration" may be initiated only after an initial registration has been established). Answer "yes" or "no" to the following questions: A. Will applicant maintain registration with a broker-dealer that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Section 12 (Employment History). B. Will applicant maintain registration with an investment adviser that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Section 12 (Employment History). Yes Yes No No American LegalNet, Inc. www.USCourtForms.com Rev. FORM U-4 (03/2002) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: ___-__-____ FIRM CRD #: 4. SRO REGISTRATIONS Check appropriate SRO Registration requests. Qualifying examinations will be automatically scheduled if needed. If you are only scheduling or re-scheduling an exam, skip this section and complete Section 7 (EXAMINATION REQUESTS). 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) NASD NYSE AMEX BSE CSE PCX CBOE CHX PHLX ISE REGISTRATION CATEGORY DP - Direct Participation Program Principal (S39) OR -Options 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 NASD NYSE AMEX BSE CSE PCX CBOE CHX PHLX ISE REGISTRATION CATEGORY 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) Other ___________________________________ (Paper Form Only) NASD NYSE AMEX BSE CSE PCX CBOE CHX PHLX ISE American LegalNet, Inc. www.USCourtForms.com Rev. FORM U-4 (03/2002) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: ___-__-____ FIRM CRD #: 5. JURISDICTION REGISTRATION Check appropriate jurisdiction(s) for AG (Broker-Dealer Agent) and/or RA (Investment Adviser Representative) registration requests. 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