Rev. Form U4 (10/2005) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 1. GENERAL INFORMATION FIRST NAME: FIRM CRD #: FIRM Billing Code: MIDDLE NAME: FIRM NAME: INDIVIDUAL CRD #: LAST NAME: SUFFIX: EMPLOYMENT DATE (MM/DD/YYYY): INDIVIDUAL SSN: Yes No Do you have an independent contractor relationship with the above named firm?: Office of Employment Address: Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: CITY: COUNTRY: Located At Supervised From START DATE: STATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: CITY: COUNTRY: START DATE: Located At Supervised From STATE: POSTAL CODE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: CITY: COUNTRY: START DATE: Located At Supervised From STATE: POSTAL CODE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: OFFICE OF EMPLOYMENT ADDRESS STREET 2: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. 2. FINGERPRINT INFORMATION Electronic Filing Representation By selecting this option, I represent that I am submitting, have submitted, or promptly will submit to the appropriate SRO a fingerprint card as required under applicable SRO rules; or Fingerprint card barcode __________________________________________________ By selecting this option, I represent that I have been employed continuously by the filing firm since the last submission of a fingerprint card to CRD and am not required to resubmit a fingerprint card at this time; or, By selecting this option, I represent that I have been employed continuously by the filing firm and my fingerprints have been processed by an SRO other than NASD. I am submitting, have submitted, or promptly will submit the processed results for posting to CRD. Exceptions to the Fingerprint Requirement By selecting one or more of the following two options, I affirm that I am exempt from the federal fingerprint requirement because I/filing firm currently satisfy(ies) the requirements of at least one of the permissive exemptions indicated below pursuant to Rule 17f-2 under the Securities Exchange Act of 1934, including any notice or application requirements specified therein: Rule 17f-2(a)(1)(i) Rule 17f-2(a)(1)(iii) Investment Adviser Representative Only Applicants I affirm that I am applying only as an investment adviser representative and that I am not also applying or have not also applied with this firm to become a broker-dealer representative. If this radio button/box is selected, continue below. I am applying for registration only in jurisdictions that do not have fingerprint card filing requirements, or I am applying for registration in jurisdictions that have fingerprint card filing requirements and I am submitting, have submitted, or promptly will submit the appropriate fingerprint card directly to the jurisdictions for processing pursuant to applicable jurisdiction rules. Page 1 of 28 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U4 (10/2005) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 3. REGISTRATION WITH UNAFFILIATED FIRMS Some jurisdictions prohibit "dual registration," which occurs when an individual chooses to maintain a concurrent registration as a representative/agent with two or more firms (either BD or IA firms) that are not affiliated. Jurisdictions that prohibit dual registration would not, for example, permit a broker-dealer agent working with brokerage firm A to maintain a registration with brokerage firm B if firms A and B are not owned or controlled by a common parent. Before seeking a dual registration status, you should consult the applicable rules or statutes of the jurisdictions with which you seek registration for prohibitions on dual registrations or any liability provisions. Please indicate whether the individual will maintain a "dual registration" status by answering the questions in this section. (Note: An individual should answer 'yes' only if the individual is currently registered and is seeking registration with a firm (either BD or IA) that is not affiliated with the individual's current employing firm. If this is an initial application, an individual must answer 'no' to these questions; a "dual registration" may be initiated only after an initial registration has been established). Answer "yes" or "no" to the following questions: A. B. Will applicant maintain registration with a broker-dealer that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Section 12 (Employment History). Will applicant maintain registration with an investment adviser that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Section 12 (Employment History). Yes No Page 2 of 28 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U4 (10/2005) UNIFORM APPLICATION FOR SECURITIES INDUSTRY REGISTRATION OR TRANSFER INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: FIRM CRD #: 4. SRO REGISTRATIONS Check appropriate SRO Registration requests. Qualifying examinations will be automatically scheduled if needed. If you are only scheduling or re-scheduling an exam, skip this section and complete Section 7 (EXAMINATION REQUESTS). REGISTRATION CATEGORY OP - Registered Options Principal (S4) IR - Investment Company & 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 (S12) 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 B