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

What Is Form S-5 (SFN51529)?

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 January 1, 2022;
  • 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-5 (SFN51529) 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-5 (SFN51529) "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 Dept 414
SFN 51529 (1-2022)
Bismarck ND 58505
(701) 328-2910
www.securities.nd.gov
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)
Telephone Number
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 Employer or Prospective Employer
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
Yes
No
SELF-EMPLOYED:
7. Complete the following employment record for the ten-year period immediately preceding the date of application.
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
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?
Yes
No
If "yes" with which exchange are you registered and for how long have you been so registered?
FORM S-5
APPLICATION FOR REGISTRATION OF AGENT
Securities Department
NORTH DAKOTA SECURITIES DEPARTMENT
600 E Boulevard Ave Dept 414
SFN 51529 (1-2022)
Bismarck ND 58505
(701) 328-2910
www.securities.nd.gov
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)
Telephone Number
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 Employer or Prospective Employer
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
Yes
No
SELF-EMPLOYED:
7. Complete the following employment record for the ten-year period immediately preceding the date of application.
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
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?
Yes
No
If "yes" with which exchange are you registered and for how long have you been so registered?
SFN 51529 (1-2022)
Page 2 of 4
10. Have you ever offered for sale or sold securities in the State of North Dakota prior to the date of this application?
No
If "yes", explain fully.
Yes
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).
Yes
12. Have you ever been denied or been given qualified authority to sell securities in any state or province?
No
13. Are you now or have you ever been subject to any revocation, cancellation, withdrawal, suspension, or
any adverse order or directive of FINRA, any Canadian self-regulatory association, any securities
Yes
No
exchange, or any state, provincial, or federal agency which has the power to revoke, suspend, or deny
membership or registration?
14. Have you ever been permanently or temporarily enjoined by any court from engaging in or continuing
Yes
No
any or practice involving any aspect of the securities business?
15. Has any broker or dealer with whom you were associated in any capacity when such action was taken
Yes
No
ever had its membership or registration denied, canceled, suspended, or revoked or been the subject
of any injunctive proceeding involving securities?
16. Have you ever been a direct or beneficial owner of 10% or more of the stock of or interest in or an
Yes
No
officer of a securities dealer whose registration was denied, canceled, suspended, or revoked during
such period of interest or employment?
17. Have you every been a subject of any arrests, information, presentments, indictments, or convictions
Yes
No
for any felony or misdemeanor, except minor traffic offenses?
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
Yes
No
20. (a) Have you ever been refused a surety or fidelity bond?
Yes
No
(b) Has any surety company paid out any funds on your coverage?
21. Have you or any organization owned or controlled by you or in which you were or are an officer,
Yes
No
director, or 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 IN A
SEPARATE DOCUMENT ATTACHED TO 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;
• IDENTIFICATION 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.
SFN 51529 (1-2022)
Page 3 of 4
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)
THE APPLICANT HEREBY UNDERTAKES AND AGREES TO PROMPTLY FILE AMENDMENTS WITH THE COMMISSIONER IF AT
ANY TIME THE INFORMATION PROVIDED HEREIN 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 EMPLOYER, FINRA OR ANY STATE, PROVINCIAL, OR FEDERAL SECURITIES REGULATORY AGENCY.
THE UNDERSIGNED APPLICANT, BEING FIRST DULY SWORN, DEPOSES AND SAYS THAT THEY HAVE EXECUTED THE
FOREGOING APPLICATION: THAT THEY HAVE READ THE APPLICATION AND KNOW THE CONTENTS THEREOF AND
ATTACHED THERETO; AND THAT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF THE STATEMENTS MADE IN THE
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 CIRCUMSTANCES UNDER WHICH IT IS
MADE, WOULD BE FALSE OR WHOULD TEND TO BE MISLEADING IN RESPECT TO ANY MATERIAL FACT.
Signature of Applicant
Date
For Notary:
State of
County of
Affix Notary Stamp
Date
Signed and sworn to (or
affirmed) before me this
Name of Individual Making Statement
Signature of Notary Public or Other Authorized Officer
SFN 51529 (1-2022)
Page 4 of 4
ENDORSEMENT OF APPLICATION BY
ISSUER 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, and of good standing and reputation.
THEREFORE, in view of the showing made herein _________________________________________________________
(Name of Issuer)
does respectfully ask that ____________________________________________________________________________________
(Name of Applicant)
be registered as a securities agent in conformity with Section 10-04-10 of the North Dakota Securities Act of 1951, as amended.
Date
Corporate Seal
Signed and Sealed on
Name of Issuer
Authorized Signatory
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