Form U-5 Uniform Termination Notice For Securites Industry Registration {U-5}

Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: FIRM NAME: INDIVIDUAL CRD #: FIRM CRD #: NOTICE TO THE INDIVIDUAL WHO IS THE SUBJECT OF THIS FILING Even if you are no longer registered you continue to be subject to the jurisdiction of regulators for at least two years after your registration is terminated and may have to provide information about your activities while associated with this firm. Therefore, you must forward any residential address changes for two years following your termination date or last Form U5 amendment to: CRD Address Changes, P.O. Box 9495, Gaithersburg, MD 20898-9495. 1. GENERAL INFORMATION FIRST NAME: FIRM CRD #: INDIVIDUAL CRD #: Office of Employment Address: CRD BRANCH #: ORegistered ONon-Registered NYSE BRANCH CODE#: FIRM BILLING CODE: MIDDLE NAME: FIRM NAME: INDIVIDUAL SSN: INDIVIDUAL NFA#: LAST NAME: SUFFIX: FIRM NFA#: FIRM Billing Code: O Located At O Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: STATE: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. CRD BRANCH #: ORegistered ONon-Registered NYSE BRANCH CODE#: FIRM BILLING CODE: O Located At O Supervised From STATE: START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. CRD BRANCH #: ORegistered ONon-Registered NYSE BRANCH CODE#: FIRM BILLING CODE: O Located At O Supervised From STATE: START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: CITY: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. 2. CURRENT RESIDENTIAL ADDRESS NOTICE TO THE FIRM: This is the last reported residential address. If this is not current, please enter the current residential address. ADDRESS STREET 1: ADDRESS STREET 2: FROM (MM/YYYY): TO (MM/YYYY): CITY: COUNTRY: STATE: POSTAL CODE: 3. FULL TERMINATION Is this a FULL TERMINATION? O Yes O No Note: A "Yes" response will terminate ALL registrations with all SROs and all jurisdictions. Reason For Termination: O Discharged O Other O Permitted to Resign O Deceased O Voluntary Termination Explanation: If the Reason for Termination entered above is Permitted to Resign, Discharged or Other, provide an explanation below: If amending the Reason for Termination and/or termination explanation, provide an explanation below: Page 1 of 24 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: FIRM NAME: INDIVIDUAL CRD #: FIRM CRD #: 4. DATE OF TERMINATION Date Terminated (MM/DD/YYYY): _______________________________ A complete date of termination is required for full termination. This date represents the date the firm terminated the individual's association with the firm in a capacity for which registration is required. For partial termination, the date of termination is only applicable to post-dated termination requests during the renewal period. Notes: For full termination, this date is used by jurisdictions/SROs to determine whether an individual is required to requalify by examination or obtain an appropriate waiver upon reassociating with another firm. The SRO/jurisdiction determines the effective date of termination of registration. If amending the Date of Termination, provide an explanation below: Page 2 of 24 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: FIRM NAME: INDIVIDUAL CRD #: FIRM CRD #: 5. PARTIAL TERMINATION For a partial termination, do not complete the Reason for Termination in Section 3 (FULL TERMINATION) or Section 7 (DISCLOSURE QUESTIONS). The Reason for Termination and Section 7 (DISCLOSURE QUESTIONS) should only be completed on Form U5 for full termination requests. 5A. SRO PARTIAL TERMINATION If this is a PARTIAL TERMINATION, mark the appropriate SRO registration categories to be terminated. NYSE-MKT BATS-YX BATS-ZX FINRA TOPAZ EDGA EDGX ARCA CBOE NYSE PHLX REGISTRATION CATEGORY MIAX BOX CHX NQX NSX C2 ISE BX OP - Registered Options Principal (S4) IR - Investment Company and 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 (S10) 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) RS - Research Analyst (S86, S87) RP - Research Principal 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 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) FP - Municipal Fund (S51) IF - In-Firm Delivery Proctor MM - Market Maker Authorized Trader-Options (S56) FB - Floor Broker (S56) MB - Market Maker acting as Floor Broker OT - Authorized Trader (S7) Page 3 of 24 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U5 (05/2009) UNIFO