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CertifiCation and authorization form
for a Criminal history
BaCkground
CheCk

Directions: Please complete all of the sections on this form.
1. Name

Dr.
Mr.
Mrs.
Ms.

(
Last

First

Middle

)
Maiden Name (if applicable)

2. Mailing
Address
Street or P.O. Box

City

State

3. E-mail Address:

ZIP code

Investment Adviser

Issuer Agent

(You MUST use the mailing address on file as it appears on the Form U4. If this address is not current, please amend your
Form U4
as soon as possible so that there is no delay in the background check process.)

4. Date of birth

/
Month

/
Day

7. Social Security number

5. Sex:

Male

Female 6. Daytime telephone number

Year

/

(Include area code)

/

8. Individual CRD or state registration number

9. Have you completed the fingerprinting process by IDEMIA or MorphoTrust for the New Jersey Bureau of Securities or
Division of Consumer Affairs since May 2012?
Yes
No
If “Yes,” please provide the date on which you were fingerprinted:
/
/
Month

Day

Year

I