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Insert A [All Privacy Act Notices should be in separate boxes]
(space)
Board of Governors of the Federal Reserve System 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 as described in the system of Records entitled BGFRS-17”
FRB --Municipal or Government Securities Principals or Representatives,” available at https://www.federalreserve.gov/files/
BGFRS-17-municipal-or-government-securities-principals-and-representatives.pdf. 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.
(space)
Federal Deposit Insurance Corporation Privacy Act Notice
The Federal Deposit Insurance Corporation 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 9 of the Federal
Deposit Insurance Act (12 U.S.C. 1819). 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 FDIC'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 in accordance with any of the other routine uses described in FDIC
30-64-0016, Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and
U.S. Government Securities Brokers/Dealers System of Records available at www.fdic.gov/about/privacy. If you have
questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at
Privacy@fdic.gov.
(space)
Office of the Comptroller of the Currency Privacy Act Notice
The Office of the Comptroller of the Currency is authorized to request this information from you by 12 U.S.C. 1, 481, 1464,
1818, and 1820; 15 U.S.C. 78o-4, 78o-5, 78q, and 78w. The purpose of collecting the information is for the OCC to carry out
its responsibilities under the federal securities laws relating to the professional qualifications and fitness of individuals who
engage or propose to engage in securities activities on behalf of national banks, federal savings associations, and District of
Columbia savings associations operating under the OCC's regulatory authority. Failure to provide the requested information in
whole or in part may delay or prevent 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 Bank
Securities Dealers System --Treasury/Comptroller system of record notice (Treasury/CC .210) available at https://
www.federalregister.gov/documents/2016/01/19/2016-00763/privacy-act-of-1974-as-amended-system-of-records. If you have
any questions or concerns about the collection or use of the information, you may contact the Deputy Comptroller, Market
Risk Division, Office of the Comptroller of the Currency, 400 Seventh St S.W., Suite 7W-215, Washington D.C. 20219.

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0RQWK'D\File Typeapplication/pdfFile TitleUniform Application for Municipal Securities Principal or Municipal Securities Representative Associated with a Bank Municipal SSubjectUniform Application for Municipal Securities Principal or Municipal Securities Representative Associated with a Bank Municipal SAuthorFederal Reserve BoardFile Modified2019-06-11File Created2018-04-16