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Seller Profile Type: BD RIA Assets

If BD or RIA, please complete Part I and Part II.
If Assets, please complete Part I and Part III.

Part I

Date:

* Owner Name: CRD #: SS#:

* Firm Name: CRD #:

Address:

City: State: Zip:

* Telephone: Fax:

* E-Mail:

Part II

State of Formation: Year Formed:

Type of Entity: Sub S C Corp LLC Other

Type of BD/RIA Shell (Dormant) Producing

If Producing: Number of Accounts Average Monthly Production:

Desired Price Range:

Net Capital: $5k $50k $100k $250k

Market Making: Yes No If yes, how many markets:

Specific products and services you are authorized to offer:

Existing Principals to stay on: Yes NoIf yes, how long:

Number of owners/shareholders:

Branch Offices: number of existing: number of permitted: none

Registered Reps: number of existing: number of permitted:

Blue Skied States:

Introducing Firm: If introducing, name of Clearing Firm:

Application Way: Self Clearing:

Regulatory Actions: Yes No

If yes, describe::

Additional Specifications:

Part III

Dollar Value of Assets Under Management:

Number of Accounts:

Location of Assets/Accounts:

Number of Branches to be Sold: Location:

Other Assets:

Additional Specifications:

* The security word must be typed to process your request: security word: is:

ALL INQUIRIES WILL BE KEPT IN THE STRICTEST OF CONFIDENCE