Form MSD-4 Uniform Application for Municipal Securities Principal o

DG 04-25-2013_v1_11:17

Board of Governors of the Federal Reserve System OMB Number 7100-0100 Approval expires April 30, 2016
Federal Deposit Insurance Corporation
OMB Number 3064-0022 Approval expires December 31, 2014
Office of the Comptroller of the Currency
OMB Number 1557-0184 Approval expires April 30, 2013
Page 1 of 5

DRAFT

Board of Governors of the Federal Reserve System

Uniform Application for Municipal Securities Principal or
Municipal Securities Representative Associated with a
Bank Municipal Securities Dealer—Form MSD-4
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. §§ 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.

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, NW, 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.
04/2013

DG 04-25-2013_v1_11:17

Form MSD-4
Page 2 of 5

DRAFT

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:

3. Office of Employment of Applicant:

A.
Name

B.

4. Date of Employment with MSD:
Registration Number

C.
Main Street Address

City

Month/Day/Year

State

Zip Code

5. To be filed with the following (check one):
Board of Governors of the Federal Reserve System

Federal Deposit Insurance Corporation

Comptroller of the Currency

6. Type(s) of Qualification Requested (check all that apply):
Municipal Securities Representative
Municipal Securities Sales Limited Representative
Municipal Securities Principal

Government Securities Representative
Government Securities Supervisor

7. It is anticipated that the applicant will perform the following functions in the capacity indicated (check all that apply):
CAPACITY
NonSupervisory Supervisory

A. Underwriting, trading or sales of municipal securities
B. Financial advisory or consultant services for issuers in connection with the issuance of municipal securities
C. Research or investment advice with respect to municipal securities in connection with the activities
described in items 7.A and 7.B above
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
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
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.
Person Contacted
Employer

Name

Position

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. §§ 1001 and 1005, and 15 U.S.C. 78ff.)

Print Name of Municipal Securities Principal

Signature of Municipal Securities Principal

Date

04/2013

DG 04-25-2013_v1_11:17

Form MSD-4
Page 3 of 5

DRAFT
Personal History of Applicant
9.

10.
Social Security Number (optional)

Name (Last, First, Middle)

11.

13.
Resident Street Address

Date of Birth (Month/Day/Year)

14.

12.
City

State

Zip Code

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

To

(MM/YYYY) (MM/YYYY)

Position
Held

Full-time or
Part-time

Reason for
Leaving

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:
Address
Street
State/Province

Zip/Postal Code

Zip/Postal Code

Country

City/Town
Zip/Postal Code

Street
State/Province

Country

City/Town

Street
State/Province

To
(MM/YYYY)

City/Town

Street
State/Province

From
(MM/YYYY)

Country

City/Town
Zip/Postal Code

Country

04/2013

DG 04-25-2013_v1_11:17

Form MSD-4
Page 4 of 5

DRAFT
Personal History of Applicant—Continued
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

No

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

Approximate Date

Type of Examination

Approximate Date

(MM/YYYY)

(MM/YYYY)

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

No

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

Basis for Exemption or Waiver Approximate Date

Type of Examination

Basis for Exemption or Waiver Approximate Date

(MM/YYYY)

(MM/YYYY)

Yes

No

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

No

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

No

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

No

A. Was your registration denied, suspended or revoked? .........................................................................

Yes

No

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

No

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

No

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

No

19. Are you currently bonded? ..................................................................................................................
If the answer to any of the following questions is Yes, attach complete details:

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

Signature of Municipal Securities Principal

Date
04/2013

DG 04-25-2013_v1_11:17

DRAFT
Acknowledgement for:

Form MSD-4

Form MSD-4
Page 5 of 5

Form G-FIN-4

26.
Applicant Name

27.
Bank Municipal Securities Dealer Name

28.

Receipt Stamp
Bank Municipal Securities Dealer Address

City

State

Zip Code

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.
Board of Governors of the Federal Reserve System
Market and Liquidity Risk Section
Mail Stop 185
20th and C Streets, NW
Washington, DC 20551
Federal Deposit Insurance Corporation
Division of Supervision
Securities, Capital Markets, and Trust Branch
Room F-2052
550 17th Street, NW
Washington, DC 20429
The Office of the Comptroller of the Currency
Treasury and Market Risk, (MS 7-1)
250 E. Street, SW
Washington, DC 20219

04/2013