SEC 1707 Form ADV Execution

FORM ADV (Paper Version)
UNIFORM APPLICATION FOR INVESTMENT ADVISER
REGISTRATION
AND
REPORT BY EXEMPT REPORTING ADVISERS
DOMESTIC INVESTMENT ADVISER EXECUTION PAGE
You must complete the following Execution Page to Form ADV. This execution page must be signed and
attached to your initial submission of Form ADV to the SEC and all amendments.

Appointment of Agent for Service of Process
By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint the Secretary
of State or other legally designated officer, of the state in which you maintain your principal office and
place of business and any other state in which you are 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 your investment
advisory 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 you maintain your
principal office and place of business or of any state in which you are submitting a notice filing.

Signature
I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the investment adviser. The
investment adviser and I both certify, under penalty of perjury under the laws of the United States of
America, that the information and statements made in this ADV, including exhibits and any other
information submitted, are true and correct, and that I am signing this Form ADV Execution Page as a free
and voluntary act.
I certify that the adviser’s books and records will be preserved and available for inspection as required by
law. Finally, I authorize any person having custody or possession of these books and records to make them
available to federal and state regulatory representatives.

Signature:

____________________________

Date:

______________________

Printed Name: ____________________________

Title:

______________________

Adviser CRD Number: _____________________

SEC 1707 (09-11)
File 4 of 4

FORM ADV (Paper Version)
UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION
AND
REPORT BY EXEMPT REPORTING ADVISERS
STATE-REGISTERED INVESTMENT ADVISER EXECUTION PAGE
You must complete the following Execution Page to Form ADV. This execution page must be signed and attached
to your initial application for state registration and all amendments to registration.

1. Appointment of Agent for Service of Process
By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint the legally designated
officers and their successors, of the state in which you maintain your principal office and place of business and any
other state in which you are applying for registration or amending your registration, 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 your investment advisory 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 you
maintain your principal office and place of business or of any state in which you are applying for registration, or
amending your registration.

2. State-Registered Investment Adviser Affidavit
If you are subject to state regulation, by signing this Form ADV, you represent that, you are in compliance with the
registration requirements of the state in which you maintain your principal place of business and are in compliance
with the bonding, capital, and recordkeeping requirements of that state.

Signature
I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the investment adviser. The
investment adviser and I both certify, under penalty of perjury under the laws of the United States of America, that
the information and statements made in this ADV, including exhibits and any other information submitted, are true
and correct, and that I am signing this Form ADV Execution Page as a free and voluntary act.
I certify that the adviser’s books and records will be preserved and available for inspection as required by law.
Finally, I authorize any person having custody or possession of these books and records to make them available to
federal and state regulatory representatives.

Signature:

____________________________

Date:

______________________

Printed Name: ____________________________

Title:

______________________

Adviser CRD Number: _____________________

FORM ADV (Paper Version)
UNIFORM APPLICATION FOR INVESTMENT ADVISER
REGISTRATION
AND
REPORT BY EXEMPT REPORTING ADVISERS
NON-RESIDENT INVESTMENT ADVISER EXECUTION

PAGE 1

You must complete the following Execution Page to Form ADV. This execution page must be signed and
attached to your initial submission of Form ADV to the SEC and all amendments.

1. Appointment of Agent for Service of Process
By signing this Form ADV Execution Page, you, the undersigned adviser, irrevocably appoint each of the
Secretary of the SEC, and the Secretary of State or other legally designated officer, of any other state in
which you are 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 your investment advisory 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 any state in which you are 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.

3. Non-Resident Investment Adviser Undertaking Regarding Books and Records
By signing this Form ADV, you also agree to provide, at your own expense, to the U.S. Securities and
Exchange Commission at its principal office in Washington D.C., at any Regional or District Office of the
Commission, or at any one of its offices in the United States, as specified by the Commission, correct,
current, and complete copies of any or all records that you are required to maintain under Rule 204-2 under
the Investment Advisers Act of 1940. This undertaking shall be binding upon you, your heirs, successors
and assigns, and any person subject to your written irrevocable consents or powers of attorney or any of
your general partners and managing agents.

NON-RESIDENT INVESTMENT ADVISER EXECUTION

PAGE 2

Signature
I, the undersigned, sign this Form ADV on behalf of, and with the authority of, the non-resident investment
adviser. The investment adviser and I both certify, under penalty of perjury under the laws of the United
States of America, that the information and statements made in this ADV, including exhibits and any other
information submitted, are true and correct, and that I am signing this Form ADV Execution Page as a free
and voluntary act.
I certify that the adviser’s books and records will be preserved and available for inspection as required by
law. Finally, I authorize any person having custody or possession of these books and records to make them
available to federal and state regulatory representatives.

____________________________

Date:

______________________

Printed Name: ____________________________

Title:

______________________

Signature:

Adviser CRD Number: _____________________