Secretary of the commonwealth securities division one ashburton place



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THE COMMONWEALTH OF MASSACHUSETTS

SECRETARY OF THE COMMONWEALTH

SECURITIES DIVISION

ONE ASHBURTON PLACE

BOSTON, MASSACHUSETTS 02108

SECTION 202(a) AFFIDAVIT FOR AN

INDIVIDUAL WAIVING AUTOMATIC AGENT REGISTRATION

This affidavit is made and filed with the Office of the Secretary of the Commonwealth, Massachusetts Securities Division for the purpose of excepting from the definition of Agent the individual named herein who, otherwise, automatically would be registered pursuant to M.G.L. c.110A, Section 202(a).

­­­_____________________________________ hereby swears or affirms:

Name of Affiant




  1. I am a/an/the _____________________of _________________________________

Title Name of Broker-Dealer

a broker-dealer registered or seeking registration in the Commonwealth of Massachusetts.


2. In that capacity, I do not effect or attempt to effect purchases or sales of securities in the
Commonwealth or engage in any other activity which falls within the definition of agent
and, will not engage in such activity unless and until such time as I become duly
registered as a broker-dealer or agent in the Commonwealth and pay to the

Commonwealth the fee required by Section 202(b) of the Massachusetts Securities Act,


M.G.L. c.110A.

Signed under the penalties of perjury this __________ day of ____________________, 20_____



_________________________________________

Signature of Affiant

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