Idaho Department of Finance

Annual Renewal For Issuer Agent License Or Non-FINRA Broker/Dealer Agent License

TO BE COMPLETED BY ISSUER/NON-FINRA BROKER/DEALER (FIRM)

Pursuant to the provisions of the Uniform Securities Act (2004) of the State of Idaho, the undersigned hereby makes application for renewal license of Agent of
(issuer or broker/dealer firm)    ,
Permit/License No.                                 
and in compliance therewith, submits the following information:
Agent Name:  
License No:  
Social Security No:
Residential address:  
City:  State:  Zip  
If above-named agent has changed his/her name, please indicate previous name :
Issuer or Broker/Dealer Firm Physical Address:
City: State: Zip:
To which email address would you like the form summary be sent?    
1.  Has agent been the subject of any complaint, investigation, administrative or injunctive proceedings, either permanent or temporary, involving securities, insurance or any other financial transaction during the past year? If so, please submit a full explanation in (or attached to) an email to securities@finance.idaho.gov 
2. Has agent been convicted of any crime or is there any action pending other than traffic violations during the past year, or has agent been denied the right to sell securities in any other state or been barred from any profession? If so, please submit a full explanation in (or attached to) an email to securities@finance.idaho.gov
3.  Has agent, or any organization owned or controlled by agent or in which agent was an officer, director or partner, been the subject of any insolvency or bankruptcy proceedings during the past year? If so, please submit a full explanation in (or attached to) an email to securities@finance.idaho.gov 
4.  Will agent devote full time to the position of securities sales agent? If answer is "no", please explain in (or attached to) an email from agent’s present employer granting agent permission to engage as a part time securities sales agent if one is not on file with this department, sent to securities@finance.idaho.gov 

Note: a Fifty Dollar ($50.00) license fee must accompany each application. You will have an opportunity to pay online after submitting this renewal.

By affixing my name to this application I, ,  hereby certify, (i) that I am an authorized agent of the applicant described and identified in this application for renewal licensure of agent, (ii)that I am the person who submitted the answers to each of the questions listed in this applicaton, and (iii) that the information I have provided in connection with the submission of this application is truthful, correct, complete and free of fraud, misrepresentation, or omission of material fact.

I will ensure that any information subsequently submitted to the Idaho Department of Finance in conjunction with this application or its supporting documents meet the same standard as set forth above.


By affixing my name, date of birth, and mother's maiden name, and submitting this application electronically, I understand that I am as fully responsible for the contents herein as though I had signed and submitted this application manually.
Dated this

Name:  
Date of Birth:  
Mother's Maiden Name:  
Title:
Address:
City State: Zip