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I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false I am subject to punishment. Social Security number / / 8. Individual CRD or state registration number 6. Have you completed the fingerprinting process by 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 / / If you were fingerprinted by MorphoTrust after May 2012 as part of the criminal history background process for registration by the Bureau of Securities or the New Jersey Division of Consumer Affairs you will not be required to be fingerprinted a second time. O. Box City 3. E-mail Address State ZIP code Investment Adviser Issuer Agent You MUST use the mailing address on file as it appears on the Form U4. Best of my knowledge and belief. I understand that any omissions inaccuracies or failure to make full disclosures may be deemed sufficient to withhold renewal of revoke suspend or restrict a registration issued by the Bureau of Securities. Name Dr. Mr. Last First Middle Maiden Name if applicable Ms. 2. Mailing Address Street or P. However you must complete the Certification and Authorization form indicating the date on which you were fingerprinted and include a fee of For a complete list of frequently asked questions please visit our website at www. F.R. 20 N.J.A. C. 13 59-1. 1 et seq. What if I previously completed the Certification and Authorization form and have gone through the Criminal History Record Background Check process for the Bureau of Securities If you have already undergone the Criminal History Record Background Check process for the Bureau of Securities you will not be required to be fingerprinted a second time. Do I have to undergo the process again Yes because the regulation concerning the dissemination of criminal history record information prohibits the sharing of the material for any reason other than the authorized and intended purpose for which it was gathered. 28 C. 4. Date of birth / / Month Day Sex Male Year Female 6. Daytime telephone number Include area code 5. However a criminal history background check must be performed each time you apply for registration* 7. I hereby acknowledge that the Bureau may approve my registration in advance of receiving the results of my Criminal History Background Check. Should any information be returned that would have caused my registration to be denied or subject me to a restricted registration the Bureau may revoke suspend or restrict my registration accordingly. Signature of applicant Date Frequently Asked Questions I recently had a background check done for another New Jersey agency e*g* the Department of Banking and Insurance. I hereby acknowledge that the Bureau may approve my registration in advance of receiving the results of my Criminal History Background Check. Should any information be returned that would have caused my registration to be denied or subject me to a restricted registration the Bureau may revoke suspend or restrict my registration accordingly.