Deferral Request Form - Broker-Dealer

THE COMMONWEALTH OF MASSACHUSETTS

SECRETARY OF THE COMMONWEALTH

SECURITIES DIVISION

ONE ASHBURTON PLACE

BOSTON, MASSACHUSETTS 02108

DEFERRAL REQUEST FORM—BROKER DEALER

___________________________________________________ hereby amends its

Name of Firm

application for registration as a broker-dealer in Massachusetts and requests an extension of the

thirty-day time period set forth in M.G.L. c.110A, Section 202(a) for action by the Massachusetts

Securities Division with respect to the application.

The undersigned hereby certifies that he/she has the authority to amend the application

and make this request on behalf of _________________________________________________

Name of Firm

and do so pursuant to that authority.

__________________________________________

Signature

__________________________________________

Print Name and Title

__________________________________________

Date

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Parent category: Legal