Page 1 of 2 Indiana Secretary of State Securities Division Application for Broker Dealer Registration SUBMIT THIS COVER SHEET AND ALL REQUESTED DOCUMENTS TO: STEPHEN NELSON - COMPLIANCE OFFICER 302 West Washington Street, Room E-111 Indianapolis, IN 46204 stnelson@sos.in.gov FIRM INFORMATION Name of Firm CRD Number of Firm Contact Person Email Address Telephone Address ( Firm ) City State Zip Code Have you filed with the CRD to request registration in Indiana? Y es N o Have you filed with the CRD to request registration in Indiana for all agents you wish to register in Indiana? Yes No Will th e f irm have a branch office or a gent in Indiana? If yes, please attach a copy of the Certificate of Authority of a Foreign Corporation to Transact Business in Indiana. Y es N o What is the f irm222s fiscal year end? PRINCIPAL INFORMATION Name of First Principal CRD Number Name of Second Principal CRD Number Is there a request for a w aiver of the two p rincipal requirement? If yes, please see checklist below Y es N o CHECKLIST FOR WAIVER OF THE TWO PRINCIPAL R EQUIREMENT Under 710 Ind. Admin. Code 247 4 - 7 - 2(d)(4), certain criteria must be met to receive a waiver of the Broker Dealer two principal requirement. The Broker Dealer must notify the Indiana Securities Division, in writing, of the following two items: (1) The Broker Dealer maintains NO branch offices anywhere. (2) The Broker Dealer employs NO MORE than ten agents anywhere. Please submit your request for the two principal waiver, along with the other requested documents. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 REQUESTED DOCUMENTS Please s ubmit the following d ocuments with the cover sheet : (1) The firm222s most recent audited financial statements. (2) The firm222s most recent FOCUS Report. If the firm does not yet have audited financial statements and/or a FOCUS Report, please forward an unaudited balance sheet not older than 60 days. (3) If the firm222s most recent audited financial statements and FOCUS report are over 60 days old, please include an unaudited balance sheet. (4) If the firm will have a branch office or agent living in Indiana, attach a copy of the Certificate of Authority of a Foreign Corporation to Transact Business in Indiana. Questions regarding audited financials and FOCUS I and/or II contact Doreen Fuery, Senior Accountant at (317 ) 232 - 0737 . PROCESS TO REQUEST AN EXAM WAIVER If an a gent is seeking an exam waiver, send the request directly to: Daniel Spungen, Registrations Attorney 226 dspungen@sos.in.gov Send the request on company letterhead via pdf copy, and include the individual222s name, CRD number, exam and registration history. Mr. Spungen will consider the request and respond within 30 days. FILING REQUIREMENTS / HELPFUL RESOURCES 1) Broker Dealer applications are filed through the CRD, along w ith a filing fee of $250.00 and the Form BD. 2) FINRA members register all agents through the CRD, along with a filing fee of $25.00 and the Form U4. 3) All amendments to the Form BD are to be filed through the CRD. 4) The opening, relocation and/or closing of branch offices is done through the CRD on the Form BR. 5) The Division requires that you register two principals in Indiana. Principals and Indiana branch managers must pass a principal222s exam. 6) A Certificate of Authority of a Foreign Corporation to Transact Business is required only if the applicant intends to have an agent living in the State of Indiana or if it maintains a branch office in Indiana. If you have any questions on how to obtain a Certificate of Authority of a Foreign Corporation to Transact Business in Indiana, please contact the Business Services Division at (317) 232-6576 or www.in.gov/sos/business/index.htm 7) The Division has 30 days to review a completed application for registration before the registration becomes effective. This 30 day period will not begin until all materials requested are received by the Division. 8) Exam information can be found at http://www.finra.org/industry/qualification-exams . American LegalNet, Inc. www.FormsWorkFlow.com