Mock-up of new Form ADV-NR

OMB APPROVAL

APPENDIX G

OMB Number:
3235-0240
Expires:
October 31, 2013
Estimated average burden
hours per response......................... 1.00

Form ADV-NR
APPOINTMENT OF AGENT FOR SERVICE OF PROCESS BY NON-RESIDENT
GENERAL PARTNER AND NON-RESIDENT MANAGING AGENT OF AN
INVESTMENT ADVISER
You must submit this Form ADV-NR if you are a non-resident general partner or a non-resident managing agent of
any investment adviser (domestic or non-resident). Form ADV-NR must be signed and submitted in connection
with the adviser’s initial Form ADV submission. If the mailing address you list below changes, you must file an
amended Form ADV-NR to provide the current address. If you become a non-resident general partner or a nonresident managing agent after the date the adviser files its initial Form ADV, you must file Form ADV-NR with the
Commission within 30 days of the date that you became a non-resident general partner or a non-resident managing
agent. If you serve as a general partner or managing agent for multiple advisers, you must submit a separate Form
ADV-NR for each adviser.

1. Appointment of Agent for Service of Process
By signing this Form ADV-NR, you, the undersigned non-resident general partner or non-resident managing agent,
irrevocably appoint each of the Secretary of the SEC, and the Secretary of State, or equivalent officer, of the state in
which the adviser referred to in this form maintains its principal office and place of business, if applicable, and any
other state in which the adviser is applying for registration, amending its registration, or submitting a notice filing, as
your agents to receive service, and agree that such persons may accept service on your behalf, of any notice,
subpoena, summons, order instituting proceedings, demand for arbitration, or other process or papers, and you
further agree that such service may be made by registered or certified mail, in any federal or state action,
administrative proceeding or arbitration brought against you in any place subject to the jurisdiction of the United
States, if the action, proceeding or arbitration: (a) arises out of any activity in connection with the investment
adviser’s business that is subject to the jurisdiction of the United States, and (b) is founded, directly or indirectly,
upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act
of 1939, the Investment Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation
under any of these acts, or (ii) the laws of the state in which the adviser referred to in this Form maintains its
principal office and place of business, if applicable, or of any state in which the adviser is applying for registration,
amending its registration, or submitting a notice filing.

2. Appointment and Consent: Effect on Partnerships
If you are organized as a partnership, this irrevocable power of attorney and consent to service of process will
continue in effect if any partner withdraws from or is admitted to the partnership, provided that the admission or
withdrawal does not create a new partnership. If the partnership dissolves, this irrevocable power of attorney and
consent shall be in effect for any action brought against you or any of your former partners.

SEC 2565 (MM-11)

FORM ADV-NR

PAGE 2

Signature
I, the undersigned non-resident general partner or non-resident managing agent, certify, under penalty of perjury
under the laws of the United States of America, that the information contained in this Form ADV-NR is true and
correct and that I am signing this Form ADV-NR as a free and voluntary act.

Signature of Partner or Agent:
_____________________________________
Printed Name: ____________________________

Date: _________________________
Title:

_________________________

Mailing Address of Partner or Agent (no P.O. Boxes):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature of Investment Adviser:
_________________________________

Date: _______________________________

Printed Name: ________________________

Title: _______________________________

Adviser SEC File Number: 801-__________

or

802-__________

Adviser CRD Number: _________________
Adviser Name: _______________________________________________________________
PRIVACY ACT STATEMENT. Section 211(a) of the Advisers Act [15 U.S.C. § 80b-11(a)] authorizes the Commission to collect the information required
by Form ADV-NR. The Commission collects this information to ensure that a non-resident general partner or managing agent of an investment adviser
appoints an agent for service of process in the United States. Filing Form ADV-NR is mandatory for non-resident general partners and non-resident
managing agents of investment advisers. The Commission maintains the information submitted on Form ADV-NR and makes it publicly available. The
Commission may return forms that do not include required information. Intentional misstatements or omissions constitute federal criminal violations under
18 U.S.C. § 1001 and 15 U.S.C. § 80b-17. The information contained in Form ADV-NR is part of a system of records subject to the Privacy Act of 1974, as
amended. The Commission has published in the Federal Register the Privacy Act System of Records Notice for these records.
SEC’S COLLECTION OF INFORMATION. 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 control number. Section 211(a) of the Advisers Act authorizes the Commission to collect the information on this Form
from applicants. See 15 U.S.C. § 80b-11(a). Filing of this Form is mandatory for non-resident general partners or managing agents of investment advisers.
The principal purpose of this collection of information is to ensure that a non-resident general partner or managing agent of an investment adviser appoints
an agent for service of process in the United States. The Commission will maintain files of the information on Form ADV-NR and will make the
information publicly available. Any member of the public may direct to the Commission any comments concerning the accuracy of the burden estimate on
page one of Form ADV-NR, and any suggestions for reducing this burden. This collection of information has been reviewed by the Office of Management
and Budget in accordance with the clearance requirements of 44 U.S.C. § 3507.