Cal. Code Regs. tit. 10 § 1805.204.1

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 1805.204.1 - Statement of Qualifications

The statement of qualifications required pursuant to Item 8 of Section 1805.204 of these rules shall be in the following form:

DEPARTMENT OF BUSINESS OVERSIGHT STATE OF CALIFORNIA

Department of Business Oversight File No.__________

STATEMENT OF QUALIFICATIONS TO BE FILED BY AN INCORPORATOR, OFFICER OR DIRECTOR OF AN APPLICANT FOR A SECURITIES DEPOSITORY CERTIFICATE OR OF A LICENSED SECURITIES DEPOSITORY.

1. Name of Securities Depository or Applicant:

___________________________

2. Full name of incorporator, officer or director:

___________________________

3. Residence address of the person named in Item 2:

___________________________

4. Identifying Information:

	a. [ ] Male [ ] Female	b. Citizenship___________________________
	c. Date of birth___/___/___	d. Place of birth___________________________

5. Capacity in which this statement is filed: (check applicable box) [ ] Incorporator [ ] Director [ ] Officer

6. If an officer of the applicant/securities depository, state title: __________

7. If you are an officer or will perform any managerial functions for the applicant/securities depository, describe such functions fully, specifically identifying the operations and/or offices of the applicant/securities depository over which you will have supervision:

___________________________

8. State the college or university degrees received and the dates received, and the school awarding each degree.

___________________________

9. List all employments which you believe relate to your qualifications to perform your duties as specified in Items 5, 6 and/or 7 above, stating the name of the employer, the duties performed and the dates of such employment.

Inclusive Dates of Employment	Name of Employer	Duties Performed Position Held
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

10. Have you, or are you, within the 10 years immediately preceding the filing of this statement:

A. Been either (1) convicted of or pleaded nolo contendere to a felony or misdemeanor, or (2) held liable in a civil action by final judgment of a court based upon conduct showing moral turpitude, which felony, misdemeanor or judgment (i) involved the purchase or sale of any security, (ii) arose out of the conduct of the business of a broker-dealer, investment adviser, or commodity adviser, (iii) involved embezzlement, fraudulent conversion or misappropriation of property, fund or securities, or (iv) involved the violation of Sections 1341, 1342 or 1343 of Title 18 of the United States Code;

________________________________________ [ ] Yes [ ] No; or

B. Permanently or temporarily enjoined by order, judgment, or decree of any court of competent jurisdiction from acting as an investment adviser, underwriter, or broker-dealer, or as an affiliated person or employee of any investment company, bank or insurance company, or from engaging in or continuing any conduct or practice in connection with any such activity or in connection with the purchase or sale of any security;

________________________________________ [ ] Yes [ ] No; or

C. Subject to any currently effective order of the Securities and Exchange Commission or the securities administrator of any other state denying registration to or revoking or suspending the registration of such person as a broker or dealer or investment adviser or subject to any currently effective order of any national securities association or national securities exchange (as defined in the Securities Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange?

[ ] Yes [ ] No

If the answer to any of the foregoing is "yes," or any such action is pending, set forth on a separate sheet in reasonable detail the facts with respect thereto.

11. Have you ever been known personally by, or conducted business under, any other name than that shown in Item 2 above?

________________________________________ [ ] Yes [ ] No; If "yes," attach a statement giving full details.

12. Signature to this statement by person named in Item 2 above: ______________________________

I declare under penalty of perjury that I have read this statement and the attachments hereto, if any, called for by Items 10 and 11 above, and know the contents thereof, and that the statements therein are true.

Executed at _________________________ California, ____________________20_____.

______________________________

(Signature of Person Named in Item 2 Above)

(INSTRUCTION: If executed outside of California, attach a verification executed and sworn to before a notary public.)

Cal. Code Regs. Tit. 10, § 1805.204.1

1. Amendment filed 9-12-73; effective thirtieth day thereafter (Register 73, No. 37).
2. Editorial correction adding NOTE filed 3-9-83 (Register 83, No. 11).
3. Editorial correction of NOTE filed 6-24-83 (Register 83, No. 26).
4. Change without regulatory effect amending section filed 9-25-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 39).
5. Change without regulatory effect amending form filed 8-13-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 33).

Note: Authority cited: Sections 30006 and 30204, Financial Code. Reference: Sections 30204, 30205 and 30206, Financial Code.