NEW JERSEY BUREAU OF SECURITIES 153 Halsey Street, 6th Floor Post Office Box 47029 Newark, NJ 07101 Telephone (973) 504-3600 Fax (973) 504-3601 E-mail: askbureauofsecurities@lps.state.nj.us INFORMATION REQUEST FORM FOR CENTRAL REGISTRATION DEPOSITORY AND/OR INVESTMENT ADVISER REGISTRATION DEPOSITORY INFORMATION INSTRUCTIONS: This form should be completed to request information available from the Central Registration Depository (CRD) and/or the Investment Adviser Registration Depository (IARD) pertaining to agents, broker-dealers, and/or investment advisers. Both pages of this form should be read and completed before signing and submitting. 1. Requested by: Name: ___________________________________________________________________ Address: _________________________________________________________________ City: _________________________________ State: __________ ZIP Code: __________ Telephone: ____________________________ Fax: ______________________________ E-mail address: ____________________________________________________________ 2. Name of agent: ____________________________________________________________ Firm affiliation: ___________________________________________________________ Identifying information: CRD/IARD #:__________________ SS#:___________________ Information requested: ______________________________________________________ 3. Name of broker-dealer: _____________________________________________________ Information requested: ______________________________________________________ 4. Name of investment adviser: _________________________________________________ Information requested: ______________________________________________________ 5. Reason for request: _________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 2 6. The Bureau of Securities reserves the right to charge for copies of documents in excess of 20 pages at the rate of $.25 per page. 7. The Bureau of Securities cannot guarantee the accuracy or completeness of the information furnished in reply to your request. Undisclosed information may exist in other jurisdictions or with self-regulatory bodies. The Bureau of Securities is not responsible for information obtained from other sources. 8. The Bureau of Securities has not passed upon the merits or qualifications of, or recommended or given approval to, any person, security, or transaction. The fact that a person or security has been registered does not constitute a finding by the Bureau of Securities that any document filed is true, complete, or not misleading. 9. If you wish to request any additional documentation, you may submit a request pursuant to the Right to Know Law, N.J.S.A. sec. 47:1A-1 et seq. (“OPRA”). For information concerning an OPRA request for Bureau of Securities records, you must contact Consumer Affairs at (973) 424-8111 or www.nj.gov/lps/opra . I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT WITH REGARD TO THE FURNISHING BY THE BUREAU OF SECURITIES OF THE INFORMATION REQUESTED. PLEASE SEND ME THE DOCUMENTS AND/OR INFORMATION REQUESTED ABOVE. _____________________________________ Signature _________________________ Date Form NJBOS-4 08/2008 American LegalNet, Inc. www.FormsWorkflow.com