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D #: FIRM NAME: FIRM CRD #: 1. GENERAL INFORMATION FIRST NAME: MIDDLE NAME: LAST NAME: FIRM CRD #: FIRM NAME: EMPLOYMENT DATE(MM/DD/YYYY): FIRM Billing Code: INDIVIDUAL CRD #: INDIVIDUAL SSN: Do you have an independent contractor relationship with the above named firm?: SUFFIX: O Yes O No Office of Employment Address: CRD BRANCH #: ORegistered ONon-Registered NYSE BRANCH CODE#: FIRM BILLING CODE: START DATE: END DATE: O Located At O Supervised From OFFICE OF EMPLOYMENT ADDRESS.

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