Form MSD-4 Uniform Application for Muncipal Securities Principal or

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 December 31, 2011
Office of the Comptroller of the Currency
OMB No. 1557-0184 Expires April 30, 2007

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, and the Office of the Comptroller of the
Currency 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.

PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by Sections 15B(c), 15C, 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C. 78o-4, 78o-5, and 78q
and 78w); and Section 9 of the Federal Deposit Insurance Act (12 U.S.C. 1819). The purpose for collecting the information is to comply with the registration requirements of
municipal securities dealers, municipal securities representatives, and U.S. Government securities brokers or dealers and associated persons contained in the Securities
Exchange Act of 1934, and to support the FDIC's regulatory and supervisory functions. Furnishing the requested information is mandatory. Failure to provide the requested
information in whole or in part may delay or prohibit the determination of your compliance with applicable registration and professional qualifications requirements. The
information you provide is protected by the Privacy Act, 5 USC 552(a). The information may be furnished to third parties as authorized by law and used according to any of
the routine uses described in the Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and U.S. Government Securities
Brokers/Dealers System of Records (30-64-0016) available at http://www.fdic.gov/regulations/laws/rules/2000-4050.html#200030--64--0016. If you have questions or
concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at [email protected].”

FORM MSD-4
Uniform Application for
Municipal Securities Principal or Municipal Securities Representative
Associated with a Bank Municipal Securities Dealer

1.

APPLICANT NAME
Last

2.

First

Middle (if none, write “n/a”)

BANK MUNICIPAL SECURITIES DEALER:
A.

NAME

B.

REGISTRATION NUMBER

C.

MAIN ADDRESS

3.

OFFICE OF EMPLOYMENT OF APPLICANT

4.

DATE OF EMPLOYMENT WITH MSD

5.

Month
TO BE FILED WITH THE FOLLOWING (check one):
Board of Governors of the Federal Reserve System...G
Comptroller of the Currency...G

6.

TYPE(S) OF QUALIFICATION REQUESTED (check all that apply):
Municipal Securities Representative ....................................................... G
Municipal Securities Principal ................................................................ G

7.

Day

Year

Federal Deposit Insurance Corporation...G

Government Securities Representative................................... G
Government Securities Supervisor.......................................... G

Capacity

It is anticipated that the applicant will perform the following functions
in the capacity indicated (check all that apply):
A. Underwriting, trading or sales of municipal securities:

Supervisory

Date

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

G
G
G
G

G

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

8.

Non-Supervisory

G

E.

Processing and clearing activities with respect to municipal securities:

F.

Maintenance of records involving activities described in items 7.A through 7.E above:

G.

Training of municipal securities principals or municipal securities representatives:

N/A
N/A
N/A

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

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.)

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PERSONAL HISTORY OF APPLICANT

9.

10.
Name: Last

First

Middle

Social Security Number (optional)
12.

11.
Resident Street Address

City

State

Zip

14.

13.
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
Complete Address

Type of
Business

From
mm/yy

To
mm/yy

Position
Held

Reason For
Leaving

Full Time or
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
mm/yy

Address (Street, City, State, ZIP, Country)

2

To
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)
Yes

G

No

G

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

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

19. Are you currently bonded?

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

B.

Date

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?

Signature of Applicant

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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 of Consumer Protection
Policy and Program Development Section
Room F-6044
550 17th Street, N.W.
Washington, DC 20429

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