Form MSD-4 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 December 31, 2011
Office of the Comptroller of the Currency
OMB No. 1557-0184 Expires May 31, 2010
Office of Thrift Supervision
OMB No. 1550-0123 Expires August 31, 2011

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

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):
Comptroller of the Currency...G
Board of Governors of the Federal Reserve System...G

Office of Thrift Supervision...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.)

1

PERSONAL HISTORY OF APPLICANT

9.

10.
Name: Last

First

Middle

Social Security Number (optional)

11.

12.
Resident Street Address

City

13.

State

Zip

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
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
No G
operations principals prescribed by the Municipal Securities Rulemaking Board? Yes 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
No G
Question 18.A? Yes 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

3

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
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.

As used in these instructions and Form MSD-4:
a. The term bank municipal securities dealer
means a municipal securities dealer that is a
bank or a department or division of a bank.
4

paper.
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.

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.

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

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.

A bank municipal securities dealer that is

a

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.

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.

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.

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.

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.

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.

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
2

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;

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.

(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.

15. Item 16: Account for all time periods.
16. Item 25:
(a) Although this item relates only to

3

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)].

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:

AUTHORITY

a. in which the federal securities or banking
laws are at issue;

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

b. in which the propriety of any disclosure of
information reported on Form MSD-4 is at issue; or

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-

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.