About your Firm

Firm Name: *
Address:
City:	State/Province: Zip:
Email Address: *
Firm Website:
Firm CRD#:   MPID:
Current Net Capital ($): Regulatory Net Capital Requirement ($):

Number of Registered Representatives:	(Series 7)   (Series 6)
Number of Branches:
Parent Company Name:
Profile Completed By:	(First Name):   (Last Name):

Contacts

	First Name	Last Name	Title	Phone	Email	CRD#
Primary Contact: *
CEO:
COO:

Type of Business

Primary Type of Business:	--None-- Day Trading Discount (internet) General Securities Institutional Other (RIA, DPP) Propietary Trading		Start up Broker Dealer?:	--None-- Yes No
Date filed Form BD with NASD:			Market Maker?:	--None-- Yes No
Please list the stock symbols traded:			Participate in IPO's?:	--None-- Yes No

Current Clearing Information

Current Provider: Please select all that apply by using Ctrl + Left Click:   Not Applicable Broadcort Direct Mutual Fund First Clearing First Southwest Goldman Jefferies JP Morgan/Bear Sterns Legent Merrill Pro Mesirow NFS Penson Financial Pershing RBC Raymond James Ridge Self Start Up Sterne Agee Wedbush Morgan Non-Traditional Clearing Firm
Current Deposit ($):			Existing Contract Expiration date:

System Requirements

Current Back Office System:
Quote Vendor:
Electronic Order Entry for Clients?: --None-- No Yes   Internet Access for Clients?: --None-- Yes No
Number of Active Accounts w/positions:
How many?:	Cash Margin IRA DVP
How much in Customer Margin Debits?:
How much in Customer Free Credits?:
How much in Customer Short Credits?:
Firm Debits:
Firm Short Credit:
How much in Money Market Funds?:
Name of Current Money Market Fund:
Names of Other Money Market Funds:

Trading Activity per Month

Customer Trades	Trades per Month	Avg. Shares per Trade
Listed Equities:
OTC Equities:
Munis:
Govt Trades:
Corp Bonds:
Mutual Funds:
Options Trades:
Other:
Dealer to Dealer	Trades per Month	Avg. Shares per Month
Listed Equities:
OTC Equities:
Munis:
Govts:
Corp Bonds:
Other:

Disclosure of Arbitration Awards, Disciplinary, Financial and Regulatory Events

A) Net Cap Violations B) Regulatory Inquiries C) Ongoing Investigations D) Fines/Censures/Etc. E) Customer Complaints

Additional Requests

Please list any additional product, service or business requests:

* denotes required field.