Connecticut Sales Agent Broker-Dealer Licensing Questionnaire
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Connecticut Sales Agent Broker-Dealer Licensing Questionnaire Form. This is a Connecticut form and can be use in Blue Sky Secretary Of State.
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Tags: Connecticut Sales Agent Broker-Dealer Licensing Questionnaire, SABDQ, Connecticut Secretary Of State, Blue Sky
CONNECTICUT SALES AGENT/BROKER-DEALER LICENSING QUESTIONNAIRE
(Rev. 6/2003)
What This Form Does
The Connecticut Uniform Securities Act requires broker-dealers and agents of issuer who transact
business in or from the state to be registered. To help us with our licensing function, this form elicits
information on broker-dealers and agents of issuer involved in public and private offerings.
1.
Issuer's Name:
2.
Answer this Question Only If the Issuer WILL Use a Broker-dealer Firm for Connecticut Sales
a. Broker-dealer's name and CRD number:
b. Broker-dealer's address:
3.
Answer this Question If the Issuer Will NOT Use a Broker-dealer Firm for Connecticut Sales
a. Name the individual who will represent the issuer in offering or selling securities in
Connecticut. Corporations, partnerships and LLCs are not individuals.
b. The individual's CRD number (if any) or taxpayer identification number is:
c. Individual's address:
d. Individual's position with the issuer: [
[
] Director [
] Managing Member [
[
] Employee [
] Partner [
] Officer
] Officer of corporate general partner
] Other (e.g. finder) Specify
e. Is he or she otherwise in the business of effecting securities transactions? [
] Yes [
] No
f. If the individual is a partner, officer, director or managing member of the issuer or an officer
of a corporate general partner, will the individual receive any direct or indirect remuneration
related to offers or sales of the securities in or from Connecticut? [
] Yes [
] No
g. Will the individual be applying for agent of issuer registration? [
] Yes [
] No
h. If the individual is a broker-dealer agent who has or may receive sales compensation in
connection with the sale of the issuer's securities, enclose a copy of the brokerdealer's written approval required by Section 36b-31-6e(d) of the Regulations of
Connecticut State Agencies. [ ] Copy Enclosed [ ] Not Applicable
I certify that the foregoing responses are true, accurate and complete.
(Sign here)
Print name of signatory, and then date this form:
Position with Issuer:
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