Form MSD-4 Uniform Application for Municipal Securities Principal o

Board of Governors of the Federal Reserve System

OMB No. 7100-0100 Expires April 30, 2010

Federal Deposit Insurance Corporation

OMB No. 3064-0022 Expires October 31, 2008

Office of the Comptroller of the Currency

OMB No. 1557-0184 Expires May 31, 2010

Office of Thrift Supervision

OMB No. XXX Expires XXX

Form MSD‑4

Uniform Application for

Municipal Securities Principal or

Municipal Securities Representative

Associated with a Bank Municipal Securities Dealer

The Board of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, the Office of the Comptroller of the Currency, and the Office of Thrift Supervision are authorized to collect this information pursuant to the authority contained in the following statutes: 15 U.S.C. sections 78o‑4, 78q, and 78w.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The information provided by each respondent is considered to be confidential.

REPORTING BURDEN: Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time to gather and maintain data in the required form and to review instructions and to complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of Management and Budget, Washington, DC 20503, and, depending on your primary federal regulator, to Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, N.W. Washington, DC 20551; or to Assistant Executive Secretary, Federal Deposit Insurance Corporation, Washington, DC 20429; or to Legislative and Regulatory Analysis Division, Office of the Comptroller of the Currency, Washington, DC 20219; or to Managing Director, Examination and Supervision Policy, Office of Thrift Supervision, 1700 G Street NW, Washington, DC 20552.

FORM MSD‑4

Uniform Application for

Municipal Securities Principal or Municipal Securities Representative

Associated with a Bank Municipal Securities Dealer



1. APPLICANT NAME

Last First Middle (if none, write “n/a”)

2. BANK MUNICIPAL SECURITIES DEALER:

1. NAME

2. REGISTRATION NUMBER

3. MAIN ADDRESS

3. OFFICE OF EMPLOYMENT OF APPLICANT

3. DATE OF EMPLOYMENT WITH MSD

Month Day Year

5. TO BE FILED WITH THE FOLLOWING (check one):

Comptroller of the Currency...G Board of Governors of the Federal Reserve System...G Federal Deposit Insurance Corporation...G

Office of Thrift Supervision...G

6. TYPE(S) OF QUALIFICATION REQUESTED (check all that apply):

Municipal Securities Representative G Government Securities Representative G

Municipal Securities Principal G Government Securities Supervisor G

7. It is anticipated that the applicant will perform the following functions Capacity

in the capacity indicated (check all that apply): Supervisory Non‑Supervisory

A. Underwriting, trading or sales of municipal securities: G G

B. Financial advisory or consultant services for issuers in connection with the issuance of

municipal securities: G G

C. Research or investment advice with respect to municipal securities in connection with the activities

described in items 7.A and 7.B above: G G

D. Activities other than those specifically mentioned that involve communication directly or indirectly with

public investors in municipal securities in connection with the activities described in items 7.A and 7.B above: G G

E. Processing and clearing activities with respect to municipal securities: G N/A

F. Maintenance of records involving activities described in items 7.A through 7.E above: G N/A

G. Training of municipal securities principals or municipal securities representatives: G N/A

8. For the purpose of verifying the information furnished on this application by the applicant named in item 1 above, this institution has made inquiry

of all employers of the applicant during the immediately preceding three years, as set forth below, concerning the accuracy and completeness of the information provided, and concerning the record and reputation of the applicant as related to the ability to perform the duties for which employed or

to be employed.

NAME AND POSITION OF

EMPLOYER PERSON CONTACTED

Date Print Name of Municipal Securities Principal Signature of Municipal Securities Principal

ACCEPTANCE OF THIS FORM FOR FILING SHALL NOT CONSTITUTE ANY FINDING THAT THE INFORMATION SUBMITTED HEREIN IS TRUE, CURRENT, COMPLETE, OR NOT MISLEADING. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE FEDERAL CRIMINAL VIOLATIONS. (See 18 U.S.C. sections 1001 and 1005, and 15 U.S.C. 78ff.)

PERSONAL HISTORY OF APPLICANT



9. 10.

Name: Last First Middle Social Security Number (optional)

11. 12.

Resident Street Address City State Zip

13. 14.

Date of Birth (Month/Day/Year) Place of Birth (City, State (if applicable), Country)



15. Any other name ever used or by which known:

16. EMPLOYMENT AND EDUCATION HISTORY. The following is a complete, consecutive statement of all my employment for the past ten years starting with my immediately previous employer. (Include full- and part-time work, self employment, military service, unemployment, and full-time education). For each period of employment, list the position held at the time of leaving employment.

Name of Employer and Type of From To Position Reason For Full Time or

Complete Address Business mm/yy mm/yy Held Leaving Part Time

17. RESIDENTIAL HISTORY. The following is a complete, consecutive statement of all my residential addresses for the past five years starting with my current residence:

From To

Address (Street, City, State, ZIP, Country) mm/yy mm/yy

18. A. Have you ever taken a qualification examination for municipal securities principals, municipal securities representatives, or financial and

operations principals prescribed by the Municipal Securities Rulemaking Board? Yes G No G

If yes, state below the type of examination and the approximate date taken.



Type of Examination Approximate Date (mm/yy)

Type of Examination Approximate Date (mm/yy)

B. Have you ever been exempt from or received a waiver of the requirement to take and pass an examination of the nature specified in

Question 18.A? Yes G No G

If yes, state below the type of examination, the basis for such exemption or waiver, and, in the case of a waiver, the approximate date.

Type of Examination Basis for Exemption or Waiver Approximate Date (mm/yy)

Type of Examination Basis for Exemption or Waiver Approximate Date (mm/yy)

19. Are you currently bonded? Yes G No G



IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, ATTACH COMPLETE DETAILS:

20. Have you ever been refused coverage under a fidelity bond or has any surety company paid out any funds on

your coverage or cancelled such coverage? Yes G No G

21. Have you ever been denied membership, registration, license, permit, or certification by any federal or state

securities or federal or state bank regulatory agency, any national securities exchange, registered securities

association, or registered clearing agency? Yes G No G

22. Has any disciplinary action ever been taken against you, or any sanction imposed upon you, including any

finding that you were a cause of any disciplinary action or violated any law, rule or regulation or were an aider,

abettor, or co‑conspirator in any such violation, by any federal or state securities or federal or state bank regulatory

agency, any national securities exchange, registered securities association, or registered clearing agency? Yes G No G

23. While you were associated in any capacity with any broker, dealer or municipal securities dealer:

A. Was your registration denied, suspended or revoked? Yes G No G

B. Was your membership in any national securities exchange, registered securities association, or registered

clearing agency denied, suspended, or revoked, or was it expelled from any such organization? Yes G No G

24. Has any permanent or temporary injunction (including a cease and desist order) ever been entered against you

enjoining conduct as an investment advisor, underwriter, broker, dealer or municipal securities dealer or as an

affiliated person of any investment company, bank dealer, or municipal securities dealer or as an affiliated person

of any investment company, bank, insurance company, or enjoining any conduct related to such activities or any

transactions in any security? Yes G No G

25. Have you been convicted within the past ten years of any felony or misdemeanor: (i) involving the purchase or

sale of any security, the taking of a false oath, the making of a false report, bribery, perjury, burglary, or conspiracy

to commit any such offense; (ii) arising out of the conduct of the business of a broker, dealer, municipal securities

dealer, investment adviser, bank, insurance company, or fiduciary; (iii) involving larceny, theft, robbery, extortion,

forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent conversion, or misappropriation of funds

or securities; (iv) involving crimes of concealment of assets, false oaths or claims, bribery in a bankruptcy proceeding,

mail fraud, fraud by wire (including telephone, telegraph, radio, or television), fraud or false statements? Yes G No G

Date Signature of Applicant

Acknowledgement for

FORM MSD‑4 G

FORM G‑FIN‑4 G



26. Applicant Name

27. Bank Municipal Securities Dealer Name Receipt Stamp

28. Bank Municipal Securities Dealer Address

29. Attention:

WHEN THE FORM MSD‑4 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGEMENT WILL BE STAMPED TO SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 29. THE STAMPED ACKNOWLEDGEMENT SHOULD BE RETAINED TO SUBSTANTIATE FILING.



Mail the form to the Regulator indicated in item 5



The Office of the Comptroller of the Currency

Treasury and Market Risk, (MS 7‑1)

250 E. Street, S.W.

Washington, DC 20219



Board of Governors of the Federal Reserve System

Market and Liquidity Risk Section

Mail Stop 185

20th and C Streets, N.W.

Washington, DC 20551



Federal Deposit Insurance Corporation

Division of Supervision

Securities, Capital Markets, and Trust Branch

Room F‑2052

550 17th Street, N.W.

Washington, DC 20429

Office of Thrift Supervision

Managing Director

Examination and Supervision Policy

1700 G Street NW

Washington, DC 20552

INSTRUCTIONS FOR COMPLETING AND FILING FORM MSD‑4

GENERAL INSTRUCTIONS

As used in these instructions and Form MSD‑4:

1. The term bank municipal securities dealer means a municipal securities dealer that is a bank or a department or division of a bank.

b. The term applicant means a person who is, or who seeks to be, associated with a bank municipal securities dealer as a municipal secu­rities principal or municipal securities represen­tative.

2. Form MSD‑4 is to be used by bank municipal securities dealers and applicants to comply with Municipal Securities Rulemaking Board Rule G‑7, "Information Concerning Associated Persons," which requires the filing of Form MSD‑4.

3. Bank municipal securities dealers are required to file Form MSD‑4 with the appropriate regulatory agency as set forth below:

 a. A bank municipal securities dealer that is a

state member bank of the Federal Reserve System, or a department of any such bank, or a State branch or agency of a foreign bank, is required to file with the Board of Governors of the Federal Reserve System.

b. A bank municipal securities dealer that is a

bank insured by the Federal Deposit Insurance Corporation (other than a bank which is a member of the Federal Reserve System) or a department or division of any such bank, is required to file with the Federal Deposit Insur­ance Corporation.

 c. A bank municipal securities dealer that is a

national bank or bank operating under the Code of Law for the District of Columbia, or a department or division of any such bank, is required to file with the Comptroller of the Cur­rency.

4. Copies of Form MSD‑4 may be obtained from the appropriate regulatory agency listed in instruc­tion 3.

5. An original and one copy of Form MSD‑4 and any attachments are to be filed with the appropriate regulatory agency listed in instruction 3 within ten days of association with the municipal securities dealer. A bank municipal securities dealer filing Form MSD‑4 shall retain an exact copy in its re­cords for at least three years after the applicant's employment or other association with such dealer has terminated.

6. If more space is needed to complete an answer, an appropriate designation shall be entered in the answer space provided, and one or more attach­ment sheets shall be used to complete the re­sponse. All attachments shall be submitted in the same format as the items to which response is made and shall be typed on white 8‑1/2 x 11 in. paper.

7. Form MSD‑4 and any attachments may be du­plicated by any method which produces legible copies of type size identical to that of the Form MSD‑4 on white 8‑1/2 x 11 in. paper.

8. Form MSD‑4 shall be manually signed on page 1 (bottom) by a municipal securities principal of the employing bank municipal securities dealer and on page 3 by the applicant.

9. All items on Form MSD‑4 must be completed, except that disclosure of one's social security num­ber is optional. The date on which the Form MSD‑4 is received by the appropriate regulatory agency shall be the date of filing. A Form MSD‑4 which is not prepared and executed in accordance with the applicable requirements may be returned as unac­ceptable. Acceptance for filing shall not constitute any finding that a Form MSD‑4 has been completed in accordance with those requirements or that any information reported on the form is true, current, complete, or not misleading.

10. Section 17(c)(1) of the Securities Exchange Act of 1934 requires every bank municipal securities dealer that files any application, notice, report, or document with its appropriate regulatory agency to file a copy of that application, notice, report, or document with the Securities and Exchange Com­mission (SEC). The SEC and the appropriate regulatory agencies listed in instruction 3 have devel­oped procedures under which the latter will send a copy of any application, notice, report, or document filed with them by a bank municipal securities dealer to the SEC. Accordingly, when this form is filed with the appropriate regulatory

agency, it will be deemed to have been filed with the SEC.

INSTRUCTIONS TO SPECIFIC ITEMS ON FORM

MSD‑4

11. Items 2 through 8 are to be completed by the bank municipal securities dealer employing or pro­posing to employ the applicant named in item 1. All other items are to be completed by the applicant.

12. Item 3: Give the address of the office of the bank municipal securities dealer in which the appli­cant is or will be employed.

13. Item 5: Indicate the appropriate regulatory agency as set forth in General Instruction 3.

14. Item 6: Municipal Securities Rulemaking Board Rule G‑3, "Classification of Principals and Repre­sentatives; Numerical Requirements; Testing," pro­vides a description of the functions performed by a

municipal securities principal or municipal securities representative. NOTE: If this form is being filed in lieu of Form G‑FIN‑4, check all applicable types of qualifications requested in item 6.

15. Item 16: Account for all time periods.

16. Item 25:

 (a) Although this item relates only to convictions during the past ten years, it should be noted that section 19 of the Federal Deposit Insurance Act (12 U.S.C. section 1829) prohib­its any insured bank, except with the written consent of the Federal Deposit Insurance Cor­poration, from employing any person who has ever been convicted of a criminal offense in­volving dishonesty or breach of trust;

 (b) Paragraph (iv) of this item relates only to

convictions within the past ten years under sections 152, 1341, 1342, 1343, or Chapters 25 or 47 of Title 18, United States Code.

PRIVACY ACT NOTICE FOR FORM MSD‑4

(To Accompany Form MSD‑4)



GENERAL

This information, in accordance with the Privacy Act of 1974, 5 U.S.C. 552a, is provided to those appli­cants completing Form MSD‑4 (Uniform Application for Municipal Securities Principal or Municipal Secu­rities Representative Associated with a Bank Munic­ipal Securities Dealer), which is to be filed with the appropriate regulatory agency, as defined in section 3(a)(34) of the Securities Exchange Act of 1934 [15 U.S.C. 78c(a)(34)].

AUTHORITY

Sections 15B(c)(5), 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C. 78o‑4, 78q and 78u).

PURPOSE

The appropriate regulatory agency will review the information reported on Form MSD‑4 to determine the applicant's compliance with the professional qualifications requirements for municipal securities principals and municipal securities representatives set forth in the General Rules of the Municipal Se­curities Rulemaking Board.

EFFECTS OF NONDISCLOSURE

Applicants who are or seek to be associated with a bank municipal securities dealer as municipal secu­rities principals or representatives are required to disclose the information necessary to complete Form MSD‑4, except that disclosure of one's social security number is optional. Applicants who do not disclose the necessary information may not be qualified for purposes of Municipal Securities Rulemaking Board Rule G‑2, "Standards of Profes­sional Qualification."

ROUTINE USES

The information reported in Form MSD‑4 may be routinely used by the appropriate regulatory agency as follows:

1. To refer to the appropriate government author-

ity, whether federal, state, local, or foreign, or to the appropriate self regulatory organization (SRO), such information as may indicate a violation or potential violation of law, regulation or rule.

2. To refer to the appropriate court, magistrate or administrative law judge such information as may be relevant to proceedings before any such court or judicial officer.

3. To make use of such information as may aid in the resolution of any action or proceeding:

 a. in which the federal securities or banking

laws are at issue;

 b. in which the propriety of any disclosure of

information reported on Form MSD‑4 is at is­sue; or

 c. to which the appropriate regulatory agency

or a past or present member of its staff is a party or otherwise involved in an official capac­ity.

4. To disclose to a federal, state, local or foreign government authority or SRO such information as may be necessary to obtain from such authority or organization additional information concerning the applicant's qualifications as a municipal securities principal or representative who is, or is to be, asso­ciated with a bank municipal securities dealer.

5. To disclose such information as may be neces­sary to respond to a request from a federal, state, local or foreign government authority or SRO for information needed in connection with the issuance of a license, the granting of a benefit, or similar action affecting the applicant.

6. To disclose such information as may be neces­sary to respond to any Congressional inquiry made at the request of the applicant.