NCS Online - Investment Adviser - Request for Proposal

Title:

First Name:

Middle Initial:

Last Name:

E-Mail:

Repeat E-Mail:

Street Address:

Name of Company

City:

State:

Postal Code:

Country:

Telephone Number:

Fax Number:

When do you want to start the registration process:

Home State:

Number of IA Representatives:

Do you have an office in any state
other than your Home state?

YesNo

If yes, which state(s)?

In which state(s) do you have or anticipate
having more than 5 clients?

Do you or any member of your
firm have any disciplinary history?

YesNo

Are you affiliated with a Broker Dealer?

YesNo

If yes, please supply Broker Dealer Name:

Do you have a Web site?

YesNo

If yes, please provide URL:

Do you anticipate having $25 million
or more under management within
120 days of effective status?

YesNo

Do you act as an adviser to a hedge fund?

YesNo

Do you act as an adviser to a mutual fund?

YesNo

Do you plan to use solicitors?

YesNo

Are any of your clients Qualified Plans
(not individuals in plans but the actual plan)?

YesNo

What Exams or professional
designations do you hold?

Do you require Series 65 Study materials?

YesNo

How did you hear about NCS?

Please explain your previous selection:

Notes / Comments / Instructions: