Form SFN53495 "Affidavit of Broker/Dealer Activity" - North Dakota

What Is Form SFN53495?

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 August 1, 2018;
  • 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 SFN53495 by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

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Download Form SFN53495 "Affidavit of Broker/Dealer Activity" - North Dakota

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Securities Department
AFFIDAVIT OF BROKER/DEALER ACTIVITY
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 53495 (8-2018)
(701) 328-2910
www.ndsecurities.com
Name of Applicant
Applicant does hereby certify:
1. That the above-named Applicant has offered for sale or sold securities, solicited clients, transferred clients,or
been involved in wrap-fee programs within this state. (Attach a list of names and addresses of North Dakota
residents solicited in our state.)
2. That the above-named Applicant has not offered for sale or sold any securities, solicited clients, transferred
clients, or been involved in wrap-fee programs within this state.
3. That the above-named Applicant has offered for sale and sold securities, solicited clients, transferred clients, or
been involved in wrap-fee programs within this state pursuant to an exempt transaction.
(Please specify which exemption was relied upon):
I, on behalf of the above-named applicant, acknowledge the foregoing to be truthful with full knowledge that
misrepresentation of such facts to the Securities Department of the State of North Dakota may result in administrative
action by the Department.
Signature of Officer, Partner, or Sole Proprietor
State of
County of
Date
Signed and sworn to (or
affirmed) before me this
Affix Notary Stamp
Name(s) of Individual(s) Making Statement
Signature of Notary Public or Other Authorized Officer
Date
THE INFORMATION PROVIDED ON THIS AFFIDAVIT WILL BE VERIFIED WITH YOUR CLEARING FIRM PRIOR TO
REGISTRATION APPROVAL. PLEASE PROVIDE THE FOLLOWING INFORMATION REGARDING YOUR CLEARING
FIRM (IF APPLICABLE):
Name of Clearing Firm
Name of Contract Person with Firm
Address
City
State
ZIP Code
Email Address of the Firm
Securities Department
AFFIDAVIT OF BROKER/DEALER ACTIVITY
600 E Boulevard Ave Dept 414
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck ND 58505
SFN 53495 (8-2018)
(701) 328-2910
www.ndsecurities.com
Name of Applicant
Applicant does hereby certify:
1. That the above-named Applicant has offered for sale or sold securities, solicited clients, transferred clients,or
been involved in wrap-fee programs within this state. (Attach a list of names and addresses of North Dakota
residents solicited in our state.)
2. That the above-named Applicant has not offered for sale or sold any securities, solicited clients, transferred
clients, or been involved in wrap-fee programs within this state.
3. That the above-named Applicant has offered for sale and sold securities, solicited clients, transferred clients, or
been involved in wrap-fee programs within this state pursuant to an exempt transaction.
(Please specify which exemption was relied upon):
I, on behalf of the above-named applicant, acknowledge the foregoing to be truthful with full knowledge that
misrepresentation of such facts to the Securities Department of the State of North Dakota may result in administrative
action by the Department.
Signature of Officer, Partner, or Sole Proprietor
State of
County of
Date
Signed and sworn to (or
affirmed) before me this
Affix Notary Stamp
Name(s) of Individual(s) Making Statement
Signature of Notary Public or Other Authorized Officer
Date
THE INFORMATION PROVIDED ON THIS AFFIDAVIT WILL BE VERIFIED WITH YOUR CLEARING FIRM PRIOR TO
REGISTRATION APPROVAL. PLEASE PROVIDE THE FOLLOWING INFORMATION REGARDING YOUR CLEARING
FIRM (IF APPLICABLE):
Name of Clearing Firm
Name of Contract Person with Firm
Address
City
State
ZIP Code
Email Address of the Firm