Deferral Request Form - Agent printable pdf download

Deferral Request Form - Agent

THE COMMONWEALTH OF MASSACHUSETTS

SECRETARY OF THE COMMONWEALTH

SECURITIES DIVISION

ONE ASHBURTON PLACE

BOSTON, MASSACHUSETTS 02108

DEFERRAL REQUEST FORM—AGENT

______________________________________________________________ hereby amends

Name of Firm

the application for registration of ___________________________________________________

Name of Agent

as an agent of __________________________________________________________________

Name of Firm

in Massachusetts and requests a deferral of the thirty-day time period set forth in M.G.L. c.110A,

§202 for action by the Securities Division with respect to the application.

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

make this request for a deferral on behalf of __________________________________________

Name of Firm

____________________ and on behalf of ___________________________________________

Name of Agent

and does so pursuant to that authority.

_______________________________________

Signature

_______________________________________

Print Name and Title

_______________________________________

Date

Deferral Request Form - Agent