Proposals - Broker/Dealer

Proposals - Broker/Dealer Proposal Request Sheet

Contact Information
Name:
Company:
Address:
City:	State: Zip:
Phone:	FAX: E-Mail:

How Did You Hear About Us?

Prospect's firm is currently a Broker/Dealer. (check if true)

Broker/Dealer Organization (Please tell us about your firm or proposed business)

	General Securities
	Limited Corporation Securities
	Investment Company Variable Annuities
	Direct Participation Program
Broker/Dealer will be affiliated with (please select one or more as applicable)
	Bank
	Insurance Company
	Investment Advisor
	Credit Union

Type of Business to be conducted (Please mark the one that will apply)

$200,000 Broker/Dealer

	Self Clearing
	Will Receive Customer Checks made payable to Broker/Dealer

$100,000 Broker/Dealer

	Market Making
	Proprietary Trading
	Underwritings - Firm Commitment

$50,000 Broker/Dealer

	Underwritings - Selling Group Member with Rights of Return
	Principal Trading - Riskless (Subject to 10 trade limitation on investment trading)
	Retail Brokerage

25,000 Broker/Dealer

Investment Company (Mutual Fund) / Variable Annuities Broker/Dealer - wire order basis

$5,000 Broker/Dealer

	Limited Corporation Securities (Investment Banking)
	Direct Participation Programs
	Limited General Securities (will NOT receive customer checks or securities)
	Limited Investment Company/Variable Annuities Broker/Dealer - subscription basis only

Will Prospect engage in any other investment services activities (mark all that will apply)

	Insurance
	Investment Advisory - $ Amount of Assets Under Management Federal RIA - > $25,000 in assets under management State RIA - < $25,000 in assets under management
	Financial Planning

	Prospect will do business with Retail Customers (check if true)
	Prospect will do business with Institutional Customers (check if true)
	Prospect will provide Internet Brokerage Services. (check if true)
	Prospect will have a web site. (check if true)

Type of Services Requested by Prospect:
	Initial Registration
	Continuing Education
	Pre-licensing Training
	General Operations (Please describe in detail)

Ancillary Information: