Form ID Application Individuals Submission

Form ID Questionnaire - Individuals

Please complete the below sections of the Form ID application for SEC EDGAR codes.

Email

Please enter the email address where you’d like the completed Form ID sent. Once you receive it, please sign and get it notarized, then return to us at edgar@colonialfilings.com.

Individual’s information

Individual’s full Legal Name:

First Name

Middle Name

Last Name

Conformed name:

Reformed name:

Address is for a non-U.S. location (do not select if address is for U.S. territory): *

Yes

No

Business Street Address:

Please be sure to include a business address. If you don't have one, please put your personal address, and be sure to let us know it is a personal address.

City

State

Zip/Postal Code

Country

Telephone Number

Email:

Business title/position:

Employer:

Violations of federal or state securities laws

Has the individual been criminally convicted as a result of a federal or state securities law violation, or civilly or administratively enjoined, barred, suspended, or banned in any capacity (e.g., officer or director bar, prohibition from associating with brokers, dealers, investment advisers, and/or other securities entities, or bar from participation in certain industries), as a result of a federal or state securities law violation?

Yes

No

By submitting this form, I authorize Colonial Filings to prepare and submit my Form ID to the SEC. I agree to pay $100 fee as required.