Form SEC 1414 SEC 1414 Form X-17A-19

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UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM X-17A-19
INFORMATION REQUIRED OF NATIONAL SECURITIES EXCHANGES AND

REGISTERED NATIONAL SECURITIES ASSOCIATIONS PURSUANT TO SECTIONS 17

AND 19 OF THE SECURITIES EXCHANGE ACT OF 1934 AND RULE 17a-19 THEREUNDER

REPORT OF CHANGE IN MEMBERSHIP STATUS

1. Identify the self-regulatory organization filing this report.
AMEX

BSE

CBOE

CSE

CHX

ISE

NASD

NYSE

PCX

PHLX

2. The change in membership with the reporting self-regulatory organization is:
(a)

New Membership

(b)

Termination of Membership

(c)

Suspension of Membership

(d)

Reinstatement from Suspension

(e)

Change of Address

(f)

Other Change in Membership Status

If (b), (c), (d) or (f) give a brief description of the circumstances ___________________________________________________
_______________________________________________________________________________________________________
3. Provide the following information concerning the subject.
Present Status: (a) thru (d)

To be changed to (a) thru (d)

(a) Name _____________________________________

(a) Name ________________________________________

(b)

(b)

Corporation

Partnership

Sole Proprietor

LLC

- Other ___________________

Corporation

Partnership

Sole Proprietor

LLC

- Other ___________________

(c) SEC File No. _______________________________

(c) SEC File No. _______________________________

(d) Principal Place of Business:

(d) Principal Place of Business:

_____________________________________________

_____________________________________________

(Number and Street)

(Number and Street)

_____________________________________________

_____________________________________________

(City)

(State)

(Zip Code)

(City)

(State)

(Zip Code)

4. The subject is also a member of the:
AMEX

BSE

CBOE

CSE

CHX

ISE

NASD

NYSE

PCX

PHLX

5. The examining authority and SIPC collection agent prior to this change in membership status is:
AMEX

BSE

CBOE

CSE

CHX

ISE

NASD

NYSE

PCX

PHLX

6. Name of person completing report _______________________________ Title __________________________________
Effective Date
Telephone No ______________________ Signature _________________________________ of Change ____________
(ADVISE BROKER-DEALER OF ITS OBLIGATION TO AMEND ITS FORM BD OR FILE FORM BDW)
RESERVED FOR SEC ACTION

Examining Authority Not Changed

Examining Authority Changed

From _______________ to _______________

Signature __________________________________________________________

Date __________________________

INSTRUCTIONS ON BACK
SEC 1414 (07-01)

Persons who are to respond to the collection of information
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GENERAL INSTRUCTIONS

FORM X-17A-19
1. This Form shall be completed and filed within 5 business days of the occurrence of one or more of the changes in membership
status listed in Item 2 and/or 3 on this Form or promptly upon learning that such changes will occur. If the information first
becomes available after the change in membership status has occurred, the Form shall be completed and filed promptly.
2. Original - Mail to:

U.S. Securities and Exchange Commission
Division of Market Regulation
100 F Street, N.E.
Washington, D.C. 20549-6628

Copy No. 1 - Mail to:

Securities Investor Protection Corporation

805 15th Street, N.W., Suite 800

Washington, D.C. 20005

Copy No. 2:

Retain for your files.

3. The original filed with the Securities and Exchange Commission and the copy filed with the Securities Investor Protection
Corporation shall be executed with a manual signature by a duly authorized official of the national securities exchange or
registered securities association (self-regulatory organization).
4. If the space provided in the Form for an answer to any Item is insufficient, the answer may be printed or typed on a separate
insert page or pages which shall be incorporated into the statement by reference thereto in the space provided for the Item.
5. If any Item of the Form is inapplicable, a statement to that effect shall be made following the Item.
6. Change of member’s address is required to be reported only by the examining authority.
7. Copies of this Form may be obtained from the main office of the Securities and Exchange Commission in Washington, D.C.
8. The Securities and Exchange Commission will use a copy of this Form to notify Securities Investor Protection Corporation
and the affected self-regulatory organizations of any action that is taken.

(ADVISE BROKER-DEALER OF ITS OBLIGATION TO AMEND ITS FORM BD OR FILE FORM BDW)