Form R-4 - Information To Be Furnished By Promoters, Directors, Officers And Partners Of, Issuers Or Investment Advisers - 2013 Page 2

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Form R-4
11/12
Page 2
Employer
Address
Position
Type of Business
Date of
Employment
(b)
States in which you have been licensed or registered within the last ten (10) years to
engage in the securities business.
______________________________________________________________________
(c)
Have you taken the examination given by the Financial Industry Regulatory Authority
(FINRA)?_______________ If, so, state wheather you passed, which examination and
give date.
______________________________________________________________________
(d)
Have you have been engaged in the securities business on a full time basis for the five
(5) years immediately preceding the filing of this form?
______________________________________________________________________
5. Do you own securities in this organization? ________________________________________
(a)
Kind, amount and percentage of ownership of each class ________________________
______________________________________________________________________
(b) How were they paid for? (If other than cash, explain fully.)
_______________________________________________________________________
(c)
Is payment completed? (If not, explain) ______________________________________
______________________________________________________________________
6. Have you any agreement, written or otherwise, relating to the acquisition of any additional
interest? (If “yes” give full particulars on separate sheet, marked Exhibit 1).
___________________________________________________________________________
___________________________________________________________________________

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