California Code of Regulations › Title 10 - Investment › Chapter 3 - Commissioner of Financial Protection and Innovation › Subchapter 11 - Securities Depositories › Section 1805.204.1 - Statement of Qualifications

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The statement of qualifications required pursuant to Item 8
				  of Section
				  1805.204 of these rules shall be
				  in the following form:
DEPARTMENT OF BUSINESS OVERSIGHT STATE OF
				  CALIFORNIA
Department of Business Oversight File No.__________
STATEMENT OF QUALIFICATIONS TO BE FILED BY AN INCORPORATOR,
				  OFFICER OR DIRECTOR OF AN APPLICANT FOR A SECURITIES DEPOSITORY CERTIFICATE OR
				  OF A LICENSED SECURITIES DEPOSITORY.
1. Name of Securities Depository or
				Applicant:
___________________________
2. Full name of incorporator, officer or
				director:
___________________________
3. Residence address of the person named in
				Item 2:
___________________________
4. Identifying Information:
a. [ ] Male [ ] Female
b.
						  Citizenship___________________________
c. Date of birth___/___/___
d. Place
						  of birth___________________________
5.
				Capacity in which this statement is filed: (check applicable box) [ ]
				Incorporator [ ] Director [ ] Officer
6. If an officer of the applicant/securities
				depository, state title: __________
7. If you are an officer or will perform any
				managerial functions for the applicant/securities depository, describe such
				functions fully, specifically identifying the operations and/or offices of the
				applicant/securities depository over which you will have supervision:
___________________________
8. State the college or university degrees
				received and the dates received, and the school awarding each degree.
___________________________
___________________________
___________________________
9. List all employments which you believe
				relate to your qualifications to perform your duties as specified in Items 5, 6
				and/or 7 above, stating the name of the employer, the duties performed and the
				dates of such employment.
Inclusive Dates of Employment
Name of
						  Employer
Duties Performed Position Held
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
10.
				Have you, or are you, within the 10 years immediately preceding the filing of
				this statement:
A. Been either (1) convicted
				of or pleaded nolo contendere to a felony or misdemeanor, or (2) held liable in
				a civil action by final judgment of a court based upon conduct showing moral
				turpitude, which felony, misdemeanor or judgment (i) involved the purchase or
				sale of any security, (ii) arose out of the conduct of the business of a
				broker-dealer, investment adviser, or commodity adviser, (iii) involved
				embezzlement, fraudulent conversion or misappropriation of property, fund or
				securities, or (iv) involved the violation of Sections
				1341,
				1342 or
				1343 of Title 18 of the United
				States Code;
________________________________________ [ ] Yes [ ] No;
				  or
B. Permanently or
				temporarily enjoined by order, judgment, or decree of any court of competent
				jurisdiction from acting as an investment adviser, underwriter, or
				broker-dealer, or as an affiliated person or employee of any investment
				company, bank or insurance company, or from engaging in or continuing any
				conduct or practice in connection with any such activity or in connection with
				the purchase or sale of any security;
________________________________________ [ ] Yes [ ] No;
				  or
C. Subject to any
				currently effective order of the Securities and Exchange Commission or the
				securities administrator of any other state denying registration to or revoking
				or suspending the registration of such person as a broker or dealer or
				investment adviser or subject to any currently effective order of any national
				securities association or national securities exchange (as defined in the
				Securities Exchange Act of 1934) suspending or expelling such person from
				membership in such association or exchange?
[ ] Yes [ ] No
If the answer to any of the foregoing is "yes," or any such
				  action is pending, set forth on a separate sheet in reasonable detail the facts
				  with respect thereto.