8-W Withdrawal of Agricultural Trade Merchant

OMB NO. 3038-0023

COMMODITY FUTURES TRADING COMMISSION
NATIONAL FUTURES ASSOCIATION FORM 8-W
Request for withdrawal from registration as
a Floor Broker or Floor Trader.

WITHDRAWAL FROM REGISTRATION AS A FLOOR BROKER AND/OR FLOOR TRADER
1

Registrant for which withdrawal is being requested.
NAME
SOCIAL SECURITY #1

NFA ID#
DATE OF BIRTH: (MM/DD/YY)1

2

/

/

STATE

Request for withdrawal as (Check category for which withdrawal is requested. If withdrawal is for both categories, and the
basis for withdrawal is not the same for each category, provide the basis for withdrawal for each category on a supplemental
sheet):
Floor Broker

3

PLACE OF BIRTH1: CITY

Floor Trader

Residence Address (P.O. Box Not Acceptable).1
STREET
CITY

4

STATE/COUNTRY

ZIP CODE

Address to which registration related mailings and correspondence should be directed.
STREET ADDRESS
ADDRESS
CITY

ZIP CODE

Location of your business records and those records required to be kept by regulations under the Commodity
Exchange Act.

FORM 8-W (6-97) PREVIOUS EDITIONS OBSOLETE

5

STATE/COUNTRY

STREET ADDRESS (P.O. BOX NOT ACCEPTABLE)
ADDRESS
CITY

STATE/COUNTRY

TELEPHONE (

ZIP CODE

)
AREA CODE

6

Basis for withdrawal request (Check where applicable):
I have not commenced engaging in activities requiring registration.
I have ceased engaging in activities requiring registration. The date activities ceased was:

/
MM

I will cease engaging in activities requiring registration. The date activities will cease is:

/
DD

/
MM

YY

/
DD

YY

1

May be submitted on a supplemental sheet.

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CFTC
NFA
6

FORM 8-W
(Revised 6-97)

Under CFTC Regulation 3.33 the withdrawal will become effective 30 days from the date of NFA's receipt of the request
unless the Commission denies, conditions, postpones or expedites the withdrawal. Does registration need to be withdrawn
at a date other than 30 days from NFA's receipt of this request?
Yes

No

If YES, Requested Date:
(If withdrawal is requested fewer than 30 days from NFA's receipt of the
request, such a request must include an attachment explaining the reasons for expediting the request.)
ATTACHED
7

If the withdrawal request is based on the registrant having ceased engaging in activities requiring registration as a
floor broker, then :
A. Have all customer or option customer agreements, if any, been terminated or have all customer or option customer positions, if any, been
transferred on behalf of customers or options
customers or closed?
YES

B. Are there any pending customer, option customer, leverage customer or commodity pool participant claims against the registrant, and, to the best of
the registrant's knowledge and belief, are there any
anticipated or threatened customer, option customer, leverage customer or commodity pool particiYES NO
pant claims against the registrant?
B1. If yes, attach a statement setting forth in full the
nature and extent of all such pending or anticipated
or threatened claims and what provisions have
been made by the registrant to satisfy such claims. ATTACHED

NO*

If “transferred” list recipient.

*Furnish full details on supplemental sheet(s)

CERTIFICATION
I certify that I will make all my books and records available in accordance with CFTC Regulation 1.31. Also, I have read and understand the foregoing
and represent that all information contained or incorporated in this form, including any attachments hereto, is accurate and complete.
PRINT NAME
SIGNATURE

DATE

WILLFUL FALSIFICATION, MISREPRESENTATION OR OMISSION OF ANY MATERIAL FACT REQUIRED TO BE STATED ON
THIS FORM CONSTITUTES CAUSE FOR DENIAL, SUSPENSION OR REVOCATION OF REGISTRATION AND PROSECUTION
UNDER CRIMINAL STATUTES OF THE INDIVIDUAL AND FIRM MAKING THE ABOVE CERTIFICATION.

INSTRUCTIONS
1

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Where to file. Send this form to National Futures Association, 200 West
Madison Street, Chicago, Illinois 60606-3447. A copy must also be sent to
each contract market on which the individual has been granted trading
privileges.

2

This form is for use by individuals who are requesting withdrawal from floor
broker or floor trader registration and who will continue to have granted
trading privileges on at least one designated contract market. Individuals
who no longer have granted trading privileges on any designated contract
market should not file this form as floor broker or floor trader registration
terminates once an individual no longer has granted trading privileges.