Rev. Form U4 (05/2009)
UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER
Page 15 of 39
Please Read Carefully. All signatures required on this Form U4 filing must be made in this section.
A "signature" includes a manual signature or an electronically transmitted equivalent. For purposes of an electronic form filing, a signature is effected by typing a
name in the designated signature field. By typing a name in this field, the signatory acknowledges and represents that the entry constitutes in every way, use, or
aspect, his or her legally binding signature.
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGMENT AND CONSENT This section must be completed on all initial or Temporary Registrat
ion form filings.
15B. FIRM/APPROPRIATE SIGNATORY REPRESENTATIONS This section must be completed on all initial or Temporary Re
gistration form filings.
15C. TEMPORARY REGISTRATION ACKNOWLEDGMENT This section must be completed on Temporary Registration form filings to be able
to receive
Temporary Registration.
15D. INDIVIDUAL/APPLICANT'S AMENDMENT ACKNOWLEDGMENT AND CONSENT Thi
s section must be completed on any amendment filing that amends
any information in Section 14 (Disclosure Questions) or any Disclosure Reporting Page (DRP).
15E. FIRM/APPROPRIATE SIGNATORY AMENDMENT REPRESENTATIONS This section must be completed on all
amendment form filings.
15F. FIRM/APPROPRIATE SIGNATORY CONCURRENCE This section must be completed to concur with a U4 filing made by another
firm (IA/BD) on behalf of
an individual that is also registered with that other firm (IA/BD).
15A. INDIVIDUAL/APPLICANT'S ACKNOWLEDGEMENT AND CONSENT
1. I swear or affirm that I have read and understand the items and instructions on
this form and that my answers (including attachments) are true and complete to the
best of my knowledge. I understand that I am subject to administrative, civil or
criminal penalties if I give false or misleading answers.
2. I apply for registration with the jurisdictions and SROs indicated in Section 4
(SRO REGISTRATION) and Section 5 (JURISDICTION REGISTRATION) as may
be amended from time to time and, in consideration of the jurisdictions and SROs
receiving and considering my application, I submit to the authority of the jurisdictions
and SROs and agree to comply with all provisions, conditions and covenants of the
statutes, constitutions, certificates of incorporation, by-laws and rules and
regulations of the jurisdictions and SROs as they are or may be adopted, or
amended from time to time. I further agree to be subject to and comply with all
requirements, rulings, orders, directives and decisions of, and penalties, prohibitions
and limitations imposed by the jurisdictions and SROs, subject to right of appeal or
review as provided by law.
3. I agree that neither the jurisdictions or SROs nor any person acting on their
behalf shall be liable to me for action taken or omitted to be taken in official
capacity or in the scope of employment, except as otherwise provided in the
statutes, constitutions, certificates of incorporation, by-laws or the rules and
regulations of the jurisdictions and SROs.
4. I authorize the jurisdictions, SROs, and the designated entity to give any
information they may have concerning me to any employer or prospective employer,
any federal, state or municipal agency, or any other SRO and I release the
jurisdictions, SROs, and the designated entity, and any person acting on their behalf
from any and all liability of whatever nature by reason of furnishing such information.
5. I agree to arbitrate any dispute, claim or controversy that may arise between me
and my firm, or a customer, or any other person, that is required to be arbitrated
under the rules, constitutions, or by-laws of the SROs indicated in Section 4 (SRO
REGISTRATION) as may be amended from time to time and that any arbitration
award rendered against me may be entered as a judgment in any court of
competent jurisdiction.
6. For the purpose of complying with the laws relating to the offer or sale of
securities or commodities or investment advisory activities, I irrevocably appoint the
administrator of each jurisdiction indicated in Section 5 (JURISDICTION
REGISTRATION) as may be amended from time to time, or such other person
designated by law, and the successors in such office, my attorney upon whom may
be served any notice, process, pleading, subpoena or other document in any action
or proceeding against me arising out of or in connection with the offer or sale of
securities or commodities, or investment advisory activities or out of the violation or
alleged violation of the laws of such jurisdictions. I consent that any such action or
proceeding against me may be commenced in any court of competent jurisdiction
and proper venue by service of process upon the appointee as if I were a resident of,
and had been lawfully served with process in the jurisdiction. I request that a copy of
any notice, process, pleading, subpoena or other document served hereunder be
mailed to my current residential address as reflected in this form or any amendment
thereto.
7. I consent that the service of any process, pleading, subpoena, or other document
in any investigation or administrative proceeding conducted by the SEC, CFTC or a
jurisdiction or in any civil action in which the SEC, CFTC or a jurisdiction are
plaintiffs, or the notice of any investigation or proceeding by any SRO against the
applicant, may be made by personal service or by regular, registered or certified mail
or confirmed telegram to me at my most recent business or home address as
reflected in this Form U4, or any amendment thereto,
by leaving such documents or notice at such address, or by any other legally
permissible means. I further stipulate and agree that any civil action or
administrative proceeding instituted by the SEC, CFTC or a jurisdiction may be
commenced by the service of process as described herein, and that service of an
administrative subpoena shall be effected by such service, and that service as
aforesaid shall be taken and held in all courts and administrative tribunals to be valid
and binding as if personal service thereof had been made.
8. I authorize all my employers and any other person to furnish to any jurisdiction,
SRO, designated entity, employer, prospective employer, or any agent acting on its
behalf, any information they have, including without limitation my creditworthiness,
character, ability, business activities, educational background, general reputation,
history of my employment and, in the case of former employers, complete reasons
for my termination. Moreover, I release each employer, former employer and each
other person from any and all liability, of whatever nature, by reason of furnishing
any of the above information, including that information reported on the Uniform
Termination Notice for Securities Industry Registration (Form U5). I recognize that I
may be the subject of an investigative consumer report and waive any requirement
of notification with respect to any investigative consumer report ordered by any
jurisdiction, SRO, designated entity, employer, or prospective employer. I
understand that I have the right to request complete and accurate disclosure by the
jurisdiction, SRO, designated entity, employer or prospective employer of the nature
and scope of the requested investigative consumer report.
9. I understand and certify that the representations in this form apply to all employers
with whom I seek registration as indicated in Section 1 (GENERAL INFORMATION)
or Section
6 (REGISTRATION REQUESTS WITH AFFILIATED FIRMS) of this form. I agree to
update this form by causing an amendment to be filed on a timely basis whenever
changes occur to answers previously reported. Further, I represent that, to the
extent any information previously submitted is not amended, the information
provided in this form is currently accurate and complete.
10. I authorize any employer or prospective employer to file electronically on my
behalf any information required in this form or any amendment thereto; I certify
that I have reviewed and approved the information to be submitted to any
jurisdiction or SRO on this Form U4 Application; I agree that I will review and
approve all disclosure information that will be filed electronically on my behalf; I
further agree to waive any objection to the admissibility of the electronically filed
records in any criminal, civil, or administrative proceeding.
Applicant or applicant's agent has typed applicant's name under this section to
attest to the completeness and accuracy of this record. The applicant recognizes
that this typed name constitutes, in every way, use or aspect, his or her legally
binding signature.
Date (MM/DD/YYYY) _____________________________
_______________________________________
Signature of Applicant
_______________________________________
Printed Name