Connecticut Broker-dealer Supplement Applicant Information Applicant Name: __________________________________________________________________________ Exact Name of Broker-dealer Applicant as Stated in Item 1 of Form BD IRS Number: ________________________________ Applicant’s IRS Employer Identification Number Applicant CRD Number: ______________ Connecticut law provides that no broker-dealer may be registered without the registration of at least one broker-dealer agent. Please list the name(s) and CRD number(s) of the agent(s) applying for Connecticut registration through the CRD System here: Agent Name Agent CRD Number Pre-Existing Clients The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration, that, during the two year period immediate preceding the date of its Connecticut broker-dealer application, the applicant has not transacted business as a broker-dealer in Connecticut, and, if the applicant is based in Connecticut, that the applicant has not transacted business as a broker-dealer in Connecticut or from Connecticut with persons located in another jurisdiction. The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration, that, during the two year period immediately preceding the filing of its Connecticut broker-dealer application, the applicant (you may check more than one box): Has transacted business as a broker-dealer in Connecticut. Is based in Connecticut and has transacted business as a broker-dealer from Connecticut with persons located in another jurisdiction. Attach a Separate Schedule Providing the Following: • • • • • • Each customer’s name and address The date(s) the transactions were effected Copies of written confirmations and monthly statements How each customer or client was introduced to the broker-dealer The names and CRD numbers of the agent(s) who handled each transaction The exclusion or exemption, if any, under the Connecticut Uniform Securities Act upon which the applicant relied in transacting business with each customer American LegalNet, Inc. www.FormsWorkflow.com Certification Concerning Statements of Financial Condition The undersigned certifies, on behalf of the aforementioned applicant for broker-dealer registration, that the statement(s) of financial condition submitted in connection with such application pursuant to Section 36b-9 of the Connecticut Uniform Securities Act are, to the best of the applicant's own knowledge true, and that neither the principal, nor any member, partner, officer or director of the applicant, as the case may be, has any proprietary interest in any account classified solely as that of a customer except as follows: Undertaking Not to Transact Business as a Broker-dealer Absent Registration The undersigned undertakes, on behalf of the aforementioned applicant for broker-dealer registration, that the applicant will not transact business as a broker-dealer in or from Connecticut until effectively registered as a broker-dealer in this state. Workers’ Compensation Coverage Section 31-286a(b) of the Connecticut General Statutes provides that "[o]n and after October 1, 1986, no state department, board or agency may renew a license or permit to operate a business in this state unless the applicant first presents sufficient evidence of current compliance with the workers’ compensation requirements of section 31-284." Subsection (d) of Section 3l-286a states that "[f]or purposes of this section, ’sufficient evidence’ means (1) a certificate of self-insurance issued by a workers’ compensation commissioner pursuant to Section 3l-284, or (2) a certificate of compliance issued by the insurance commissioner pursuant to Section 3l286, or (3) a certificate of insurance issued by any stock or mutual insurance company or mutual association authorized to write workers’ compensation insurance in this state or its agent." If you have questions about how Section 31-286a or Section 31-284 of the Connecticut General Statutes applies to you, please direct them to your attorney or to the Workers’ Compensation Commission at (860) 493-1500 rather than to the Department of Banking. The Applicant represents as follows (only check one box): The Applicant will not be operating a business in Connecticut within the meaning of Section 3l286a(b) of the Connecticut General Statutes and is not subject to Section 3l-284 of the Connecticut General Statutes. The Applicant will be operating a business in Connecticut within the meaning of Section 3l-286a(b) of the Connecticut General Statutes and has attached a copy of the certificate required by that section. 2 American LegalNet, Inc. www.FormsWorkflow.com Signature The undersigned, being duly sworn, does hereby certify, on behalf of the above Applicant for brokerdealer registration under the Connecticut Uniform Securities Act that he or she is authorized to execute this Connecticut Supplement on behalf of the Applicant; that the information contained herein, including any schedules and supplements included herewith, is complete, true and accurate; and that the Applicant will comply with the undertakings contained in this Connecticut Supplement. _________________________________________________________ Signature of Executive Officer or individual of similar rank Print Name of Signatory: ___________________________________ Title: ____________________________________________________ Subscribed and sworn to before me this day of 20 . ___________________________________________ Notary Public/Commissioner of the Superior Court My Commission Expires: Rev. 11/2007 3 American LegalNet, Inc. www.FormsWorkflow.com