Form MSD-4 Uniform Application for Municipal Securities Principal o

Board of Governors of the Federal Reserve System OMB Number 7100-0100 Approval expires May 31, 2019
OMB Number 3064-0022 Approval expires March 31, 2018
Federal Deposit Insurance Corporation
OMB Number 1557-0184 Approval expires May 31, 2016
Office of the Comptroller of the Currency
Page 1 of 5

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.

PRIVACY ACT NOTICE
The Federal Reserve Board is authorized to request this information from you by Sections 3, 15B(c), 15C, 17 and 23 of the Securities Exchange Act
of 1934 (15 U.S.C. 78c, 78o-4, 78o-5, and 78q and 78w); and Section 11 of the Federal Reserve Act (12 U.S.C. 248). 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 Board’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 qualification requirements. The
information you provide is protected by the Privacy Act, 5 U.S.C. 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 Municipal or Government Securities Principals and Representatives System of
Records (BGFRS-17), available at https://www.gpo.gov/fdsys/pkg/PAI-2013-BGFRS/xml/PAI-2013-BGFRS.xml#bgfrs17. If you have any questions
or concerns about the collection or use of the information, you may contact the Secretary of the Board, Board of Governors of the Federal Reserve
System, 20th Street and Constitution Avenue, NW, Washington, DC 20551.

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
Activities Division, Office of the Comptroller of the Currency, Washington, DC 20219.

05/2016

Form MSD-4
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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”)

3. Office of Employment Applicant:

2. Bank Municipal Securities Dealer:
A.
Name

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. Types(s) of Qualification Requested (check all that apply):
Municipal Securities Representative

Municipal Securities Principal

Municipal Securities Sales Limited Representative

Government Securities Representative

Municipal Securities Fund Sales Limited 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 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 (MM/DD/YYYY)
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Form MSD-4
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Personal History of Applicant
9.

10.
Name (Last, First, Middle)

Social Security Number (optional)

11.

13.
Date of Birth (Month/Day/Year)

Resident Street Address

14.

12.
City

State

Zip Code

Place of Birth (City, State(if applicable), Country)

15. Any other name ever used 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
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Form MSD-4
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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
(MM/YYYY)

Type of Examination

Approximate Date
(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
(MM/YYYY)

Type of Examination

Basis for Exemption or Waiver Approximate Date
(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, registerd 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 (Month/Day/Year

05/2016

Form MSD-4
Page 5 of 5

Acknowledgment for:

Form MSD-4

Form G-FIN-4

26.
Applicant Name

27.
Bank Municipal Securities Dealer Name

Receipt Stamp

28.
Bank Municipal Securities Dealer Address

City

State

Zip Code

29.
Attention

When the Form MSD-4 is received by the appropriate regulatory agency, this acknowledgment will be stamped to show
receipt and returned to the person named in item 29. The stamped acknowledgment should be retained to substantiate filing.

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 5.
Board of Governors of the Federal Reserve System
Submit completed forms in Portable Document Format (PDF) to the Federal Reserve’s secure email address:
[email protected]
Federal Deposit Insurance Corporation
Policy & Program Development Section
550 17th Street, NW, Room MB-5100
Washington, DC 20429
The OfficeoftheComptrolleroftheCurrency
Upload completed forms via the OCC’s BankNet website www.banknet.gov
For assistance call (202) 649-6360

05/2016