Form S-4 (SFN51526) "Application for Registration as a Dealer" - North Dakota

What Is Form S-4 (SFN51526)?

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 S-4 (SFN51526) by clicking the link below or browse more documents and templates provided by the North Dakota Securities Department.

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Download Form S-4 (SFN51526) "Application for Registration as a Dealer" - North Dakota

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Form S-4
APPLICATION FOR REGISTRATION AS DEALER
Securities Department
600 East Boulevard
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck, ND 58505
SFN 51526 (10-2013)
(701) 328-2910
www.nd.gov/securities
Pursuant to the provisions of Section 10-04-10 of the North Dakota Securities Act of 1951, as amended, application is made for registration
as a dealer:
Note: The registration fee for each dealer is $200
1. Name of Applicant
Telephone Number
Address
City
State
ZIP Code
2. Form of Business Organization
Date of Organization
State of Incorporation
3. Attach as Exhibit A the names and business addresses of all members, partners, officers, directors, trustees, managers, or
supervisory persons of the applicant.
a. List any securities qualifications examination that may have been taken by any of the persons listed in Exhibit A to
include the name of the examination, date taken, and grade attained.
b. A statement setting forth in chronological order the occupational activities of each such partner, member, officer,
director, trustee, or manager for the past ten years.
c. In the case of a new dealer, include the investment experience of those listed in (a).
4. Addresses of all branch offices and name of person in charge of each in this state:
Form S-4
APPLICATION FOR REGISTRATION AS DEALER
Securities Department
600 East Boulevard
NORTH DAKOTA SECURITIES DEPARTMENT
Bismarck, ND 58505
SFN 51526 (10-2013)
(701) 328-2910
www.nd.gov/securities
Pursuant to the provisions of Section 10-04-10 of the North Dakota Securities Act of 1951, as amended, application is made for registration
as a dealer:
Note: The registration fee for each dealer is $200
1. Name of Applicant
Telephone Number
Address
City
State
ZIP Code
2. Form of Business Organization
Date of Organization
State of Incorporation
3. Attach as Exhibit A the names and business addresses of all members, partners, officers, directors, trustees, managers, or
supervisory persons of the applicant.
a. List any securities qualifications examination that may have been taken by any of the persons listed in Exhibit A to
include the name of the examination, date taken, and grade attained.
b. A statement setting forth in chronological order the occupational activities of each such partner, member, officer,
director, trustee, or manager for the past ten years.
c. In the case of a new dealer, include the investment experience of those listed in (a).
4. Addresses of all branch offices and name of person in charge of each in this state:
SFN 51526 (10-2013)
Page 2 of 4
5. Describe briefly the general character of the business conducted or proposed to be conducted by the applicant. If application is being
made as an issuer-dealer, make a positive statement to the effect that the registration is sought for the limited purpose of selling the
issuer's own securities, stating the type and amount proposed to be offered and sold, and that the issuer-dealer is not, and will not
conduct a general securities business .
6. If this application is being made to register the applicant as an issuer-dealer, two of the officers of such issuer-dealer may be exempt
from the examination requirements. Please list the two officers and their titles for whom this exemption is being applied. They must be
officers and must register as an agent.
Name:
Position:
7. Attach as Exhibit B a list containing the name of each state in which the applicant is, or has been licensed or registered, or has filed an
application indicating type registration or license, date of effectiveness or anticipated effective date. If any registration or license has
been terminated, refused, canceled, suspended, or withdrawn in any state, give full details, including the date and reason for the
termination.
(If none, so state.)
8.
Attach as Exhibit C the names of all organizations of dealers or brokers of which the applicant is a member or before which any
application for membership on the part of the applicant is pending, and whether any such membership of the applicant has ever been
denied, revoked, suspended, or has been the subject of proceedings for revocation or suspension.
(If none, so state.)
9. List the names of any securities exchange of which the applicant or any of its partners, officers, directors, trustees,
members, managers, or employees is a member and whether any such membership has ever been denied, revoked, suspended, or is
the subject of proceedings for revocation or suspension.
(If none, so state.)
10.
Is applicant registered as a dealer under the Securities Exchange
Date
YES
NO
Act of 1934 or any Act adopted in amendment thereof?
Has any such registration of the applicant ever been denied, revoked,
Date
YES
NO
suspended, or is such registration now the subject of proceedings for
revocation or suspension by the Securities and Exchange Commission?
SFN 51526 (10-2013)
Page 3 of 4
11. State whether the applicant, or registrant, or any other person directly or indirectly controlling or controlled by the applicant or registrant,
including any officer, director, or partner:
a. Has been found by any state or federal regulatory authority or by any court to have violated any statute in
any state or federal securities act, or any rule or order or regulation promulgated under or issued pursuant
YES
NO
to such act, or to have aided, abetted, counseled, commanded, induced, or procured any such violation by
another person.
If the answer is "yes" provide the following information:
Name
Position
Type of Action
Name of Court or Agency
Name of Court or Agency
Date of Action
b.
Has ever been subject to an order of any state authority barring or suspending the right of such person to
YES
NO
be engaged in any trade or business.
If the answer is "yes" provide the following information:
Name
Position
Type of Action
Name of Court or Agency
Name of Court or Agency
Date of Action
YES
NO
c.
Has been, within the last 10 years, charged, arrested, or convicted of any felony or misdemeanor, except
minor highway traffic offenses.
If the answer is "yes" provide the following information:
Name
Position
Type of Action
Name of Court or Agency
Name of Court or Agency
Date of Action
Has filed for bankruptcy or been determined bankrupt by a court of competent jurisdiction.
d.
YES
NO
If the answer is "yes" provide the following information:
Name
Position
Type of Action
Name of Court or Agency
Name of Court or Agency
Date of Action
12. Additional exhibits as required under the North Dakota Securities Act of 1951, as amended, are listed below and included with this
application:
a.
Consent to Service of Process (Form U-2)
b.
Corporate Resolution (Form U-2 ABD)
c.
A financial statement or balance sheet prepared in accordance with standard accounting practice showing the financial
condition of the applicant as of the most recent practicable date prior to the date of application, such financial statement or
balance sheet to be certified by an independent certified public accountant.
d.
Articles of Incorporation and By-Laws, Partnership Agreement, or Member Control Agreement.
13. While this application is pending or any license issued under this application is effective, the applicant or registrant agrees to file
promptly, but no later than 30 days following the specified event or occurrence, an amended application showing any material
change including, but not limited to, the following: changes in ownership, branch managers, officers, directors, partners, actions by
any governmental agency or authority directed toward application to its registered salesmen, financial condition, etc.
SFN 51526 (10-2013)
Page 4 of 4
14. Applicant or registrant consents that notice of any proceeding or order connected with this application or
registration may be effectively given by sending notice to the person below at the address given.
Name
Title or Capacity
Address
City
State
ZIP Code
Signed and sealed this ___________ day of __________________________________, year ____________
Printed Name of Signatory
Corporate Seal
Signature of Person on Behalf of Applicant
(President, Partner, or Proprietor)
Title
ATTEST
(Secretary of Partner)
STATE OF
)
)ss.
COUNTY OF
)
The undersigned, being first duly sworn, deposes and executes the foregoing application for and on behalf of the applicant
named therein; that he is
of the applicant and is fully authorized to execute and file said
application; that he has read said application and knows the contents thereof; and that to the best of his knowledge and
belief the statements made in said application and in any exhibits attached thereto and other information filed therewith, all
of which is made a part thereof, are correct, true and complete. Applicant further represents that to the extent that
information previously submitted is not correct, such information is currently accurate and complete.
Subscribed and sworn before me this ________________ day of _____________________ year ___________
Notary Public
Notarial Seal
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