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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 ___________________________________________________

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hours per response 0.25

3. Provide the following information concerning the subject.

Present Status: (a) thru (d)

(a) Name _____________________________________

(b) Corporation Partnership Sole Proprietor 

LLC - Other ___________________

(c) SEC File No. _______________________________

(d) Principal Place of Business:

(Number and Street) 

(City) (State) (Zip Code) 

4. The subject is also a member of the:

To be changed to (a) thru (d) 

(a) Name ________________________________________

(b) Corporation Partnership Sole Proprietor

 LLC - Other ___________________

(c) SEC File No. _______________________________

(d) Principal Place of Business:

(Number and Street) 

(City) (State) (Zip Code) 

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 

Persons who are to respond to the collection of information SEC 1414 (07-01) contained in this form are not required to respond unless the 

form displays a currently valid OMB control number. 
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)