Application For Renewal Of Registration As An Agent Of An Issuer
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1S.D.4.(1997)
Agent File #
COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
APPLICATION FOR RENEWAL OF REGISTRATION AS AN AGENT OF AN ISSUER
(Print or Type)
_______________________________________________________________________________________
Last Name
First Name
Middle Name
residing at _______________________________________________________________________, hereby
Street Number
City
State
Zip
applies for a renewal of registration as an agent registered under the Securities Act, and reaffirms his
connection with the issuer specified below:
_______________________________________________________________________________________
(Name of Issuer)
_______________________________________________________________________________________
(Principal Address of Issuer)
_______________________________________________________________________________________
The address of the applicant’s place of business is to be entered here if other than the principal address of
the issuer.
In order to assist in determining whether to grant the application, check below whether or not the applicant
has been involved in any of the following during the preceding registration year.
YES
NO
Has been convicted of felony or misdemeanor involving dishonesty?
( )
( )
Has been sued for fraud, deceit or breach of trust?
( )
( )
Has been adjudicated as bankrupt?
( )
( )
Has any unsatisfied judgments against him?
( )
( )
Has been denied a registration to sell securities?
( )
( )
Has had a securities registration suspended or revoked?
( )
( )
If the issuer is unable to answer any of the above with a (NO), the renewal cannot be processed until the
situation is discussed with the Division.
CERTIFICATE
The issuer named in the foregoing renewal application certifies that the information supplied is true and
correct to the best of its knowledge and promises to notify the Commission promptly with respect to any
change in information heretofore given.
_________________________________________________________
Issuer
Date
_________________________________________________________
By
(Signature)
Title
INSTRUCTIONS
1.
Do not send separate $30.00 checks for each agent. Incorporate all fees into one check covering
all renewals. Check to be made payable to the Treasurer of Virginia.
2.
Should an investigation of the applicant be necessary, the Commission may require additional
information.
3.
If the applicant ceases to be connected with the issuer specified in the application, he and the
issuer must promptly notify the Commission giving date of termination and advising that the agent’s
record is either clear or not clear.
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