INVESTMENT ADVISOR REPRESENTATIVE U4 QUESTIONNAIRE Step 1 of 5 20% General InformationPlease complete this form on a device with a mouse. Some answers allow you to select multiple options from a list which is difficult without a mouse.Legal Full Name* First Middle Last Social Security Number (SSN)* Individual CRD #* I have an Individual CRD #. I do not yet have an Individual CRD #. List Individual CRD #.* Office of Employment Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this office of employment address a private residence?* Yes No Fingerprint InformationSome state securities regulators require fingerprint cards when registering as an investment advisor representative. An investment advisor representative applicant should review the most recent investment advisor representative registration requirements published by the applicable state securities regulator where he or she is requesting registration.Fingerprints* I am applying for registration only in jurisdictions that do not have fingerprint card filing requirements. I am applying for registration in jurisdictions that have fingerprint card filing requirements and I am submitting, have submitted, or promptly will submit the appropriate fingerprint card directly to the jurisdictions for processing pursuant to applicable jurisdiction rules. Registration with Unaffiliated FirmsWill applicant maintain registration with a broker-dealer that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Employment History.* Yes No Will applicant maintain registration with an investment adviser that is not affiliated with the filing firm? If you answer "yes," list the firm(s) in Employment History.* Yes No Jurisdiction RegistrationAs a federal advisor, our investment advisor representatives are only required to register in a state where they have a place of business or residence, with the exception of Texas. If an investment advisor representative has clients in Texas but no place of business, they must still register with the state.Select each state where you have a physical place of business or private residence. (To select multiple states, hold down the "CTRL" button and click on each state that applies.)*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingSelect each state where you have one or more clients. (To select multiple states, hold down the "CTRL" button and click on each state that applies.)*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingRegistration Requests with Affiliated FirmsWill applicant maintain registration with firm(s) under common ownership or control with the filing firm?* Yes No Professional DesignationsSelect each active designation you currently hold. Select "None of the above" if your designation is not listed. (To select multiple designations, hold down the "CTRL" button and click on each that applies.)*Certified Financial Planner (CFP)Chartered Financial Consultant (ChFC)Personal Financial Specialist (PFS)Chartered Financial Analyst (CFA)Chartered Investment Counselor (CIC)None of the aboveIdentifying InformationEnter your state, province, or country of birth.* Enter your date of birth.* Month Day Year Sex* Male Female Select your hair color.*BaldBlackBlond or StrawberryBlueBrownGray or Partially GrayGreenOrangePinkPurpleRed or AuburnSandyWhiteSelect your eye color.*BlackBlueBrownGrayGreenHazelMaroonMulticoloredPinkEnter your height.* Enter your weight.* Other NamesList any other full names used currently or in the past, including maiden name. If you have no other names to disclose, enter "N/A".* Residential HistoryStarting with the most recent address, provide all addresses for the past five (5) years. Changes must be reported as they occur. If more room is needed, please enter addresses in final comment section of this form.Start Date for Current Address* Month Day Year Current Address* Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Start Date Month Day Year End Date Month Day Year Address Street Address City State ZIP Code Employment HistoryProvide complete employment history for the past ten (10) years starting with the most recent. Account for all time including full and part-time employments, self-employment, military service, and homemaking. Also include statuses such as unemployment, full-time education, extended travel, or similar statuses. If you are using a DBA, please list the company as part of your employment history below. Changes must be reported as they occur. If more room is needed, please enter additional employment history in final comment section of this form.Firm/Company Name* Title/Position Held* Start Date* Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business?* Yes No Address* City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State Firm/Company Name Title/Position Held Start Date Month Day Year End Date (if applicable) Month Day Year Is this an investment-related business? Yes No Address City State DisclosuresPlease read each question carefully and select the "Yes" radio button if it applies. If the answer to any question is “Yes,” additional details may be requested. Please note that the question numbers begin at 14 and correspond with the system in which the U4 is filed. There are no missing questions before 14A(1)(a). 14A(1)(a) Have you ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony?* Yes No 14A(1)(b) Have you ever been charged with any felony?* Yes No 14B(1)(a) Have you ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign or military court to a misdemeanor involving: investments or an investment-related business or any fraud, false statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a conspiracy to commit any of these offenses?* Yes No 14B(1)(b) Have you ever been charged with a misdemeanor specified above in 14B(1)(a)?* Yes No 14A(2)(a) Based upon activities that occurred while you exercised control over it, has an organization ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic or foreign court to any felony?* Yes No 14A(2)(b) Based upon activities that occurred while you exercised control over it, has an organization ever been charged with any felony?* Yes No 14B(2)(a) Based upon activities that occurred while you exercised control over it, has an organization ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic or foreign court to a misdemeanor involving: investments or an investment-related business or any fraud, false statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a conspiracy to commit any of these offenses?* Yes No 14B(2)(b) Based upon activities that occurred while you exercised control over it, has an organization ever been charged with a misdemeanor specified above in 14B(2)(a)?* Yes No 14C(1) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have made a false statement or omission?* Yes No 14C(2) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have been involved in a violation of its regulations or statutes?* Yes No 14C(3) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have been a cause of an investment-related business having its authorization to do business denied, suspended, revoked, or restricted?* Yes No 14C(4) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever entered an order against you in connection with investment-related activity?* Yes No 14C(5) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever imposed a civil money penalty on you, or ordered you to cease and desist from any activity?* Yes No 14C(6) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have willfully violated any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board, or found you to have been unable to comply with any provision of such Act, rule or regulation?* Yes No 14C(7) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board?* Yes No 14C(8) Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever found you to have failed reasonably to supervise another person subject to your supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board?* Yes No 14D(1)(a) Has any other Federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever found you to have made a false statement or omission or been dishonest, unfair or unethical?* Yes No 14D(1)(b) Has any other Federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever found you to have been involved in a violation of investment-related regulation(s) or statute(s)?* Yes No 14D(1)(c) Has any other Federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever found you to have been a cause of an investment-related business having its authorization to do business denied, suspended, revoked or restricted?* Yes No 14D(1)(d) Has any other Federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever entered an order against you in connection with an investment-related activity?* Yes No 14D(1)(e) Has any other Federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever denied, suspended, or revoked your registration or license or otherwise, by order, prevented you from associating with an investment-related business or restricted your activities?* Yes No 14D(2)(a) Have you been subject to any final order of a state securities commission (or any agency or officer performing like functions), state authority that supervises or examines banks, savings associations, or credit unions, state insurance commission (or any agency or office performing like functions), an appropriate federal banking agency, or the National Credit Union Administration, that bars you from association with an entity regulated by such commission, authority, agency, or officer, or from engaging in the business of securities, insurance, banking, savings association activities, or credit union activities?* Yes No 14D(2)(b) Have you been subject to any final order of a state securities commission (or any agency or officer performing like functions), state authority that supervises or examines banks, savings associations, or credit unions, state insurance commission (or any agency or office performing like functions), an appropriate federal banking agency, or the National Credit Union Administration, that constitutes a final order based on violations of any laws or regulations that prohibit fraudulent, manipulative, or deceptive conduct?* Yes No 14E(1) Has any self-regulatory organization ever found you to have made a false statement or omission?* Yes No 14E(2) Has any self-regulatory organization ever found you to have been involved in a violation of its rules (other than a violation designated as a "minor rule violation" under a plan approved by the U.S. Securities and Exchange Commission)?* Yes No 14E(3) Has any self-regulatory organization ever found you to have been the cause of an investment-related business having its authorization to do business denied, suspended, revoked or restricted?* Yes No 14E(4) Has any self-regulatory organization ever disciplined you by expelling or suspending you from membership, barring or suspending your association with its members, or restricting your activities?* Yes No 14E(5) Has any self-regulatory organization ever found you to have willfully violated any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board, or found you to have been unable to comply with any provision of such Act, rule or regulation?* Yes No 14E(6) Has any self-regulatory organization ever found you to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board?* Yes No 14E(7) Has any self-regulatory organization ever found you to have failed reasonably to supervise another person subject to your supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the Municipal Securities Rulemaking Board?* Yes No 14F Have you ever had an authorization to act as an attorney, accountant or federal contractor that was revoked or suspended?* Yes No 14G(1) Have you been notified, in writing, that you are now the subject of any regulatory complaint or proceeding that could result in a yes answer to any part of 14C, D or E?* Yes No 14G(2) Have you been notified, in writing, that you are now the subject of any investigation that could result in a "yes" answer to any part of 14A, B, C, D or E?* Yes No 14H(1)(a) Has any domestic or foreign court ever enjoined you in connection with any investment-related activity?* Yes No 14H(1)(b) Has any domestic or foreign court ever found that you were involved in a violation of any investment-related statute(s) or regulation(s)?* Yes No 14H(1)(c) Has any domestic or foreign court ever dismissed, pursuant to a settlement agreement, an investment-related civil action brought against you by a state or foreign financial regulatory authority?* Yes No 14H(2) Are you named in any pending investment-related civil action that could result in a "yes" answer to any part of the above 14H(1) questions?* Yes No 14I(1)(a) Have you ever been named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that you were involved in one or more sales practice violations and which is still pending?* Yes No 14I(1)(b) Have you ever been named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that you were involved in one or more sales practice violations and which resulted in an arbitration award or civil judgment against you, regardless of amount?* Yes No 14I(1)(c) Have you ever been named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that you were involved in one or more sales practice violations and which was settled, prior to 05/18/2009, for an amount of $10,000 or more?* Yes No 14I(1)(d) Have you ever been named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that you were involved in one or more sales practice violations and which was settled, on or after 05/18/2009, for an amount of $15,000 or more?* Yes No 14I(2)(a) Have you ever been the subject of an investment-related, consumer-initiated (written or oral) complaint, which alleged that you were involved in one or more sales practice violations, and which was settled, prior to 05/18/2009 for an amount of $10,000 or more?* Yes No 14I(2)(b) Have you ever been the subject of an investment-related, consumer-initiated (written or oral) complaint, which alleged that you were involved in one or more sales practice violations, and which was settled, on or after 05/18/2009, for an amount of $15,000 or more?* Yes No 14I(3)(a) Within the past twenty four (24) months, have you been the subject of an investment-related, consumer-initiated, written complaint, not otherwise reported under question 14I(2) above, which alleged that you were involved in one or more sales practice violations and contained a claim for compensatory damages of $5,000 or more (if no damage amount is alleged, the complaint must be reported unless the firm has made a good faith determination that the damages from the alleged conduct would be less than $5,000)?* Yes No 14I(3)(b) Within the past twenty four (24) months, have you been the subject of an investment-related, consumer-initiated, written complaint, not otherwise reported under question 14I(2) above, which alleged that you were involved in forgery, theft, misappropriation or conversion of funds or securities?* Yes No 14I(4)(a) For arbitration claims or civil litigation filed on or after 05/18/2009: Have you ever been the subject of an investment-related, consumer initiated arbitration claim or civil litigation which alleged that you were involved in one or more sales practice violations, and which was settled for an amount of $15,000 or more?* Yes No 14I(4)(b) For arbitration claims or civil litigation filed on or after 05/18/2009: Have you ever been the subject of an investment-related, consumer initiated arbitration claim or civil litigation which alleged that you were involved in one or more sales practice violations, and which resulted in an arbitration award or civil judgment against any named respondent(s)/defendant(s), regardless of any amount?* Yes No 14I(5)(a) For arbitration claims or civil litigation filed on or after 05/18/2009: Within the past twenty four (24) months, have you been the subject of an investment-related, consumer-initiated arbitration claim or civil litigation not otherwise reported under question 14I(4) above, which alleged that you were involved in one or more sales practice violations and contained a claim for compensatory damages of $5,000 or more (if no damage amount is alleged, the arbitration claim or civil litigation, must be reported unless the firm has made a good faith determination that the damages from the alleged conduct would be less than $5,000)?* Yes No 14I(5)(b) For arbitration claims or civil litigation filed on or after 05/18/2009: Within the past twenty four (24) months, have you been the subject of an investment-related, consumer-initiated arbitration claim or civil litigation not otherwise reported under question 14I(4) above, which alleged that you were involved in forgery, theft, misappropriation or conversion of funds or securities?* Yes No 14J(1) Have you ever voluntarily resigned, been discharged or permitted to resign after allegations were made that accused you of violating investment-related statutes, regulations, rules, or industry standards of conduct?* Yes No 14J(2) Have you ever voluntarily resigned, been discharged or permitted to resign after allegations were made that accused you of fraud or the wrongful taking of property?* Yes No 14J(3) Have you ever voluntarily resigned, been discharged or permitted to resign after allegations were made that accused you of failure to supervise in connection with investment-related statutes, regulations, rules or industry standards of conduct?* Yes No 14K(1) Within the past 10 years have you made a compromise with creditors, filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition?* Yes No 14K(2) Within the past 10 years, based upon events that occurred while you exercised control over it, has an organization made a compromise with creditors, filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition?* Yes No 14K(3) Within the past 10 years, based upon events that occurred while you exercised control over it, has a broker or dealer been the subject of an involuntary bankruptcy petition, or had a trustee appointed, or had a direct payment procedure initiated under the Securities Investor Protection Act?* Yes No 14L Has a bonding company ever denied, paid out on, or revoked a bond for you?* Yes No 14M Do you have any unsatisfied judgments or liens against you?* Yes No If applicable, use this space to enter any other notes or comments.Advisor Signature*Date* MM slash DD slash YYYY