Form SFN51529 (S-5) "Application for Registration of Agent" - North Dakota

What Is Form SFN51529 (S-5)?

This is a legal form that was released by the North Dakota Securities Department - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the North Dakota Securities Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN51529 (S-5) by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

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Download Form SFN51529 (S-5) "Application for Registration of Agent" - North Dakota

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FORM S-5
APPLICATION FOR REGISTRATION OF AGENT
Securities Department
NORTH DAKOTA SECURITIES DEPARTMENT
600 E Boulevard Ave
SFN 51529 (10-2013)
Bismarck ND 58505
(701) 328-2910
www.nd.gov/securities
INSTRUCTIONS
The answers provided in this application are submitted UNDER OATH. Any applicant who willfully and contrary to such oath shall state
or subscribe any material fact which he does not believe to be true is guilty of perjury and is punishable by imprisonment in the penitentiary.
In addition, registration may be refused, suspended, or revoked if the applicant has filed an application which is incomplete in any material
respect or contains any statement which was, in the light of the circumstances under which was made, false or misleading with respect to any
material fact.
All questions in this application must be answered legibly, responsively, and fully, and failure to do so may result in rejection of the
application. If additional space is required in which to answer a question, attach a separate sheet and specify the number of the question in
response to which the answer is given.
TO THE SECURITIES COMMISSIONER OF THE STATE OF NORTH DAKOTA:
Pursuant to the provisions of Section 10-04-10 of the North Dakota Century Code, as amended, the undersigned hereby applies for
registration as a securities agent and submits the following SWORN answers to the questions contained herein:
1. Name (Last, First, Middle):
2. Indicate any other name or names (including maiden name) by which you have been known or which you have used. If "none," so state.
3. Business Address:
City:
State:
ZIP Code:
4. Residence Address:
City:
State:
ZIP Code:
5. Name of dealer employing or proposing to employ applicant. If applicant proposes to be self employed, so state. If applicant proposes to
be employed complete Item 6
6. If applicant proposes to be self-employed, please indicate so below and state the particular security or securities you propose to sell
in this state, including the name of the issuer.
Securities and Issuer:
SELF-EMPLOYED:
Yes
No
Complete the following employment record for the ten-year period immediately preceding the date of application.
7.
BEGINNING WITH THE PRESENT and continuing in chronological order. Where self-employment is applicable, furnish
the name under which business was conducted, location, and nature of business. Periods of unemployment must be
shown. Indicate reason for resignation or discharge.
From
To
Employer
Address
Position
Reason for Leaving
Month
Year
Month
Year
FORM S-5
APPLICATION FOR REGISTRATION OF AGENT
Securities Department
NORTH DAKOTA SECURITIES DEPARTMENT
600 E Boulevard Ave
SFN 51529 (10-2013)
Bismarck ND 58505
(701) 328-2910
www.nd.gov/securities
INSTRUCTIONS
The answers provided in this application are submitted UNDER OATH. Any applicant who willfully and contrary to such oath shall state
or subscribe any material fact which he does not believe to be true is guilty of perjury and is punishable by imprisonment in the penitentiary.
In addition, registration may be refused, suspended, or revoked if the applicant has filed an application which is incomplete in any material
respect or contains any statement which was, in the light of the circumstances under which was made, false or misleading with respect to any
material fact.
All questions in this application must be answered legibly, responsively, and fully, and failure to do so may result in rejection of the
application. If additional space is required in which to answer a question, attach a separate sheet and specify the number of the question in
response to which the answer is given.
TO THE SECURITIES COMMISSIONER OF THE STATE OF NORTH DAKOTA:
Pursuant to the provisions of Section 10-04-10 of the North Dakota Century Code, as amended, the undersigned hereby applies for
registration as a securities agent and submits the following SWORN answers to the questions contained herein:
1. Name (Last, First, Middle):
2. Indicate any other name or names (including maiden name) by which you have been known or which you have used. If "none," so state.
3. Business Address:
City:
State:
ZIP Code:
4. Residence Address:
City:
State:
ZIP Code:
5. Name of dealer employing or proposing to employ applicant. If applicant proposes to be self employed, so state. If applicant proposes to
be employed complete Item 6
6. If applicant proposes to be self-employed, please indicate so below and state the particular security or securities you propose to sell
in this state, including the name of the issuer.
Securities and Issuer:
SELF-EMPLOYED:
Yes
No
Complete the following employment record for the ten-year period immediately preceding the date of application.
7.
BEGINNING WITH THE PRESENT and continuing in chronological order. Where self-employment is applicable, furnish
the name under which business was conducted, location, and nature of business. Periods of unemployment must be
shown. Indicate reason for resignation or discharge.
From
To
Employer
Address
Position
Reason for Leaving
Month
Year
Month
Year
SFN 51529 (10-2013)
Page 2 of 4
8. Are you registered as a representative with the Financial Industry Regulatory Authority (FINRA)?
Yes
No
9. Are you registered as a representative with a national stock exchange?
If "yes," with
Yes
No
which exchange are you registered and for how long have you been so registered?
10. Have you ever offered for sale or sold securities in the State of North Dakota prior to the date of this application?
If "yes," explain fully.
Yes
No
11. List each state (including North Dakota) and province in which you are or have been registered as a dealer or agent to sell
securities, specifying the date(s) of such registration(s).
12. Have you ever been denied or been given qualified authority to sell securities in any state or province?
Yes
No
13. Are you now or have you ever been subject to any revocation, cancellation, withdrawal, suspension, or any adverse
order or directive of the FINRA, any Canadian self-regulatory association, any securities exchange, or any state, provincial,
or federal agency which has the power to revoke, suspend, or deny membership or registration?
Yes
No
14.
Have you ever been permanently or temporarily enjoined by any court from engaging in or continuing any conduct or
practice involving any aspect of the securities business?
Yes
No
15. Has any broker or dealer with whom you were associated in any capacity when such action was taken ever had its
membership or registration denied, canceled, suspended, or revoked or been the subject of any injunctive proceeding
involving securities?
Yes
No
16.
Have you ever been a direct or beneficial owner of 10% or more of the stock of or interest in or an officer of a securities
dealer whose registration was denied, canceled, suspended, or revoked during such period of interest or employment?
Yes
No
17.
Have you ever been a subject of any arrests, information, presentments, indictments, or convictions for any felony
or misdemeanor, except minor traffic offenses?
Yes
No
18. Have you ever been charged with fraud in civil action?
Yes
No
19. Have you ever been barred or suspended from the practice of any business or profession?
Yes
No
SFN 51529 (10-2013)
Page 3 of 4
(a) Have you ever been refused a surety or fidelity bond?
20.
Yes
No
(b) Has any surety company paid out any funds on your coverage?
Yes
No
21.
Have you or any organization owned or controlled by you or in which you were or are an officer, director, or
Yes
No
partner ever been the subject of an insolvency or bankruptcy proceeding?
IF YOUR ANSWER TO ANY ONE OF QUESTIONS 12-20 ABOVE IS "YES," FURNISH THE FOLLOWING
INFORMATION ON A SEPARATE SHEET OF PAPER INCORPORATED AS A PART OF THIS APPLICATION: NAME
OF FEDERAL, STATE, OR PROVINCIAL AGENCY, SECURITIES EXCHANGE, OR SECURITIES ASSOCIATION;
NAME AND LOCATION OF BROKER OR DEALER WITH WHOM YOU WERE ASSOCIATED AND CAPACITY IN
WHICH YOU WERE ASSOCIATED; DESIGNATION OF STATUTES, RULES, OR REGULATIONS WHICH YOU OR
THE BROKER OR DEALER WITH WHOM YOU WERE ASSOCIATED WERE CHARGED WITH VIOLATING AND
CHARGES MADE; NATURE AND DATE OF JUDGEMENT, DECISION, OR OTHER FINDINGS MADE, AND SANCTION
IMPOSED.
22. Are you currently licensed as an insurance agent?
Yes
No
If "yes," with what company or companies?
23. Please list any securities examinations that you have taken, the date(s) taken and the score(s) you obtained below.
EXAMINATION(S)
DATE(S) TAKEN
SCORE(S)
24. APPLICANT HEREBY UNDERTAKES AND AGREES TO PROMPTLY FILE AMENDMENTS WITH THE COMMISSIONER AT ANY
TIME WHEN THE INFORMATION PROVIDED HEREIN IS OR BECOMES INACCURATE OR INCOMPLETE IN ANY MATERIAL
RESPECT AND TO PROMPTLY NOTIFY THE COMMISSIONER REGARDING ANY COMPLAINT OR ACTION INVOLVING
SECURITIES FILED BY ANY PERSON AGAINST THE APPLICANT OR OF ANY DISCIPLINARY ACTION INSTITUTED OR TAKEN
AGAINST THE APPLICANT BY THE EMPLOYING DEALER, THE FINRA OR ANY STATE, PROVINCIAL, OR FEDERAL
SECURITIES REGULATORY AGENCY.
Signed and dated this
day of
Year
.
at
Printed Name of Signatory
Signature of Applicant
SFN 51529 (10-2013)
Page 4 of 4
State of
)
) ss.
County of
)
The undersigned applicant, being first duly sworn, deposes and says that he has executed the foregoing application: that he has read said
application and knows the contents thereof and attached thereto; that to the best of his knowledge and belief the statements made in said
application and in any rider attached thereto are true and correct and are complete in every material respect and do not contain any statement
which, under the circumstances under which it is made, would be false or would tend to be misleading in respect to any material fact: and that
he has read and understands the securities laws of the State of North Dakota.
(Signature of Applicant)
Subscribed and sworn to before me this
day of
Year
(Notary Public)
SEAL
County of
State of
My Commission expires
ENDORSEMENT OF APPLICATION BY
DEALER PROPOSING TO EMPLOY APPLICANT
(Do not complete if the applicant is to be a self-employed agent and Item 6 is marked yes.)
I have examined this application and the answers provided herein. They are true, to the best of my knowledge, information, and belief. I
have personally known the applicant named herein for
years, and on behalf of my firm, I hereby endorse the applicant as an
individual of sufficient knowledge in securities, of good business standing and reputation, and of high moral character, and as one who is
worthy of a securities agent's registration.
THEREFORE, in view of the showing made herein,
(Dealer proposing to employ applicant)
does respectfully ask that
(Applicant)
be registered as a securities agent in conformity with Section 10-04-10 of the North Dakota Securities Act of 1951, as amended.
Signed and sealed this
day of
Year
at
Corporate Seal
(Dealer proposing to employ applicant)
By:
(President, partner, or proprietor of dealer)
Page of 4