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Insurance, Securities and Banking

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Department of Insurance, Securities and Banking: Clean Hands Form

Transaction Certification

Department of Insurance, Securities and Banking


Please complete the information below and be prepared to respond to one of the following requirements  which will appear on the next page.  This pertains to transactions effected within the District of Columbia or with District of Columbia residents prior to registration under the District of Columbia Securities Act ["Act"].

 

Broker-Dealer Name & CRD #:

, Today's Date: