Oregon Department of Consumer and Business Services Division of Finance and Corporate Securities 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 503-378-4140  Fax: 503-947-7862 http://dfcs.oregon.gov REPRESENTATIVE/SALESPERSON TERMINATION The employer and the representative must complete this form, which should be received by the Division of Finance and Corporate Securities no less than 30 days after the termination of the representative. • Incomplete forms will not be processed. • The employer must complete and sign the Representative information and the Employer election and verification section. • The representative must complete and sign the Disciplinary Reporting Disclosure Questionnaire: Pages 2 and 3. • Send the completed form, Pages 1-3 to the address above. Representative information Employer: Representative’s name: SSN: Representative’s title: - CRD number: Representative’s phone number: - Date of birth: Representative’s home address: City: State: ZIP: Termination date of representative: Employer election and verification The undersigned has read this termination form and the attached disciplinary reporting disclosure. To the best of employer’s knowledge and belief, this information is true, correct, and complete. Name (print): Phone no.: Signature: Title: Date: 440-2118b (9/10/COM) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DISCIPLINARY REPORTING DISCLOSURE QUESTIONNAIRE Review these questions carefully and report any disclosures that have not been previously reported. Yes No 1. As of the date of termination, were or are you employed by two or more of the following Oregon-licensed entities: broker-dealer, investment adviser, securities issuer? If yes, list entities here: Has an undertaking (Form 440-2131) been executed? 2. Have you been the subject of any order or administrative action by the director of the Oregon Department of Consumer and Business Services? 3. Have you been given qualified authority or been denied authority to sell securities in any state or country? 4. Have you been the subject of any revocation, cancellation, withdrawal, suspension, or other adverse order or directive of any self-regulatory organization or any state or foreign financial regulatory authority regulating the sales of securities? 5. Have you been the subject of any investigation by any federal regulatory agency or any self-regulatory authority or any state regulating the sales of securities? 6. Have you been the subject of a U.S. Postal Service fraud order or action? 7. Have you been permanently or temporarily enjoined or restrained by any court from engaging in or continuing any conduct or practice involving any aspect of the securities business? 8. Have you been charged with fraud in any civil action? 9. Have you been convicted of, or indicted for, the commission of any felony or misdemeanor? 10. Have you been suspended or barred from the practice of any trade or profession? 11. Have you been the subject of any insolvency or bankruptcy proceeding? 12. Is your current financial condition such that you cannot meet your obligations as they mature? 13. Has any organization owned or controlled by you, or in which you were or are an officer, director, or partner, been the subject of any insolvency or bankruptcy proceeding or become defunct or inoperative during the period of your association with such organization? 14. Are there any unsatisfied judgments or suits against you for collection of obligations? 15. Have you been the subject of an investment-related consumer-initiated complaint? 16. Has any federal regulatory authority, any self-regulatory organization, or any state or foreign financial regulatory authority ever: a) Found you to have made a false statement or omission or been involved in a violation of its rules? b) Found you to have been the cause of an investment-related business having its authorization to do business denied, suspended, revoked, restricted, or disciplined you by expelling or suspending you from membership, barring or suspending your association with its members, or restricting your activities? c) Found you to have willfully violated any provisions of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board, or found you to have been unable to comply with any provision of such act, rule, or regulation? 440-2118b (9/10/COM) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Yes No d) Found you to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board? e) Found you to have failed reasonably to supervise another person subject to your supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board? 17. Are you now the subject of any complaint, investigation, or proceeding that could result in a “yes” answer to questions 2-16? For each “Yes” answer on questions 2-17, attach a Disclosure Reporting Page (from Form U-4) for each. Representative verification I hereby attest that, to the best of my knowledge, information, and belief, the information contained in this application and in the attached materials is true, correct, and complete. Date: Signature: Reminder: Amendments to Form U-4 must be submitted within 30 days of any material change (OAR 441-175-0105). 440-2118b (9/10/COM) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com