Vermont Securities Division INVESMENT ADVISER AND FEDERAL COVERED INVESTMENT ADVISER VERMONT BRANCH OFFICE FORM (Form VT-1) This form is being filed by (check one): _____ INVESTMENT ADVISER ______ FEDERAL COVERED INVESTMENT ADVISER _____ To initiate a branch office filing please complete items 1-10, 12 and Addendum to this form if required by Item(s) 8 or 9. Registration requires a $100 fee payable to the "Department of Financial Regulation." _____ To amend branch office information, complete as set forth above. No fee required. _____ To request termination of a branch office, please complete items 1-6, 10-12. No fee required. _____________________________________________________________________________________________ 1. Name and principal place of business of the investment adviser or federally covered investment adviser filing this form: ________________________________________________________________________ ______________________________________________________________________________________ Contact person for firm: _________________________________________________________________ Telephone number: _____________________________________________________________________ Investment Adviser Firm CRD number: __________________________________________ Vermont Branch Office #: ________________________________________________________________ Physical location of branch office (include street address, suite or room number, city, state and zip code): ______________________________________________________________________________________ ______________________________________________________________________________________ Mailing address (if different from above): ___________________________________________________ ______________________________________________________________________________________ If address is being amended, indicate previous location: ________________________________________ ______________________________________________________________________________________ 2. 3. 4. 5. 6. 7. Branch office phone number: _____________________________________________________________ Name and Central Registration Depository number of manager/resident investment adviser representative in charge: _____________________________________________________________________________ Is this office owned, leased, or rented by any person other than the firm filing this form? _____ NO _____ YES (If "YES", file Addendum) Will business be conducted at this branch office under any name other than that of the above-named firm? _____ NO _____ YES (If "YES", file Addendum) 8. 9. 1 American LegalNet, Inc. www.FormsWorkFlow.com 10. List each investment adviser representative working out of this office, including each representative's CRD number (attach additional sheets if necessary). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ FOR TERMINATION REQUESTS: If requesting termination, please indicate whether the investment adviser representatives working from this office are terminating their registrations or transferring to another branch office. sdlfkjsdf;lkj _____________________________________________________________________________________________ 11. TO BE COMPLETED ONLY FOR OFFICES REQUESTING TERMINATION: Termination Date: ______________________________________________________________________ Records of this office may be obtained by contacting: Name: ____________________________________________Daytime Telephone: __________________ Business Address: ______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Home Address: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Reason for Termination: _________________________________________________________________ ______________________________________________________________________________________ 12. By executing this form, the undersigned, in his or her individual capacity and on behalf of the above-named Applicant firm hereby swears and affirms that all information on this form and all materials filed in connection with it are true, correct and complete. The undersigned stipulates, recites, acknowledges and agrees that if the Vermont Securities Division finds than any information contained in this application or in an amendment to this application is false, such finding shall constitute a violation of 9 V.S.A. § 5505. Signed: ____________________________________________ Date: ____________________________ Authorized Signatory of Applicant Firm _______________________________________________________________________________ Typed Name and Title of Signatory Please mail completed form to: Department of Financial Regulation- Attn: Securities Division, 89 Main Street, 2nd Floor Montpelier, VT 05620 2 American LegalNet, Inc. www.FormsWorkFlow.com Revised 03/25/2013 ADDENDUM TO INVESTMENT ADVISER AND FEDERAL COVERED INVESTMENT ADVISER VERMONT BRANCH OFFICE FORM (Form VT-2) This addendum must be completed for each branch office which will be owned, leased or rented by any person other than the firm filing a branch office form; or for any branch office which will conduct business under a name other than that of the firm filing a branch office form. 1. Name of investment adviser or federal covered investment adviser (same as item 1 on Form VT-1): ____________________________________________________________________________________ 2. Will business be conducted at this branch office under any name other than that of the above-named firm? _____NO _____YES If "YES", provide the name(s) under which business will be conducted at this location: ____________________________________________________________________________________ 3. What types of business or services will be offered at this office? Check all that apply. _____Insurance _____Investment Advice _____Law Office _____Accounting Services _____Securities _____Financial Planning _____Tax Advice _____Banking (Specify bank)