Annual U4 and Activities Disclosure
Full Name
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First Name
Last Name
E-mail
*
Phone Number
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-
Area Code
Phone Number
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Address where you conduct securities-related activity (if different from residence)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you regularly conduct business out of any location other than the locations you entered above?
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Yes
No
Any new Professional Designations?
Certified Financial Planner
Chartered Financial Consultant
Chartered Financial Analyst
Chartered Investment Counselor
Personal Financial Specialist
Enter any changes in residence. Include the address and the starting and ending months of residence.
Enter any changes in employment. Include the employer, the starting and ending months of employment, and the city of the employer. Include any time as a student or time without employment.
Are you know by an alias or any other name (e.g. maiden name)?
Are there any Outside Business Activities currently on your U4 that are no long applicable?
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Conflict Disclosure Updates
I have disclosed all outside business activities to the firm that I either (i) receive compensation for; or (ii) participate in the management of business assets.
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Yes
No (please complete an OBA Disclosure Form for each activity)
To my knowledge, I have disclosed all personal securities accounts carried by a brokerage other than RMS, which I have a financial interest or exercise discretion over
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Yes
No (please complete a Brokerage Account Disclosure Form for each outside account)
I have disclosed all purchases and sales of private securities in which I was involved or received compensation. This includes management or performance fees received as general partner of an investment fund.
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Yes
No (please complete a Private Securities Transaction Disclosure form for each transaction)
I have disclosed all gift and gratuities that I have provided to clients of the firm.
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Yes
No (please complete a Gift Disclosure Form for each instance)
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Activities Questionnaire
Do you retain any RMS client documentation at any location?
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Yes
No
Do you receive any mail related to RMS or RMS clients at any location?
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Yes
No
Have you accepted or delivered client funds (e.g., checks) in the last 12 months?
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Yes
No
Have you accepted or delivered client securities or certificates in the last 12 months?
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Yes
No
Do you currently act as a trustee or executor, or have you been named a beneficiary, for any client accounts?
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Yes
No
Do you maintain or control a personal web site?
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Yes
No
If yes, provide each website here:
Have you borrowed from or loaned money to any clients?
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Yes
No
Do you produce research reports, executives summaries, or investor presentations for clients?
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Yes
No
Do you conduct seminars targeted to industry groups, prospective clients, or existing clients?
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Yes
No
Are you the manager or general partner of an investment fund or vehicle?
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Yes
No
In the past year, have you appeared on any undisclosed investment-related radio, TV or internet broadcast (e.g. interview, seminar, etc.)?
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Yes
No
In the last 12 months, have you participated in any , coordinated, or hosted any investment-related seminars, forums or meetings that have not been disclosed?
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Yes
No
Do you serve as a manager, officer or director for any publicly traded or private company?
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Yes
No
Are any of your clients a manager, officer or director of a public company?
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Yes
No
Do you exercise discretion or control over any client securities accounts?
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Yes
No
In the past 12 months, have you participated in any product-specific sales contests or incentive-based sales programs?
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Yes
No
Do you prepare and/or distribute personalized account statements, consolidated statements or performance reports, or any other type of statement or report that includes values of securities holdings?
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Yes
No
Do you advise clients in the structuring of securities offerings or transactions?
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Yes
No
Do you participate or anticipating participating in facilitating trades of late state, pre-IPO secondary securities?
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Yes
No
Do you participate or anticipate participating in facilitating mergers or acquisitions?
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Yes
No
Do you create or advise on the creation of marketing plans for client securities offerings?
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Yes
No
Do you participate or anticipate participating in facilitating the primary offerings of private equity or venture capital?
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Yes
No
Do you participate or anticipate participating in facilitating the primary offerings of investment fund securities?
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Yes
No
Do you participate or anticipate participating in facilitating the sale or trade of commodities?
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Yes
No
Are you dual registered with any of the following financial institutions (select all that apply)?
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another broker-dealer besides RMS
a registered investment adviser
NFA/CFTC registered firm
NONE OF THE ABOVE
Other
Do you communicate or conduct securities business using an email address other than an email that is archived and monitored by RMS?
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Yes
No
Do you use Linkedin to communicate or conduct securities business with clients?
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Yes
No
Do you use social media or messaging services other than Linkedin (e.g. Facebook, Whatsapp, Skype, WeChat etc.) to communicate or conduct securities business with clients?
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Yes
No
Do you use password (or pin, fingerprint, etc.) protection on your electronic devices (i.e. phone, pc, laptop)?
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Yes
No
Do you use virus/malware protection on your electronic devices (i.e. Windows Defender, Norton Anti-Virus, McAfee, etc.)?
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Yes
No
If you use a wireless router to connect to the internet, does the connection password protected?
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Yes
No
NA - no wireless router
To your knowledge, has any of your sensitive data related to brokerage activities been compromised via phishing, hacking, physical theft, or otherwise?
*
Yes
No
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U4 Disclosure Updates
Have you (or any organization that you controlled) ever been charged, convicted of, or pled guilty or "no contest" to any felony?
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Yes
No
Have you or any organization that you controlled ever been charged or convicted of or pled guilty or "no contest" to a misdemeanor involving investment-related business, fraudulent activity, or theft?
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Yes
No
Has any regulatory authority found you to be in violation of any investment-related regulation or statute?
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Yes
No
Has any regulatory authority found you in violation of any laws or regulations that prohibit fraudulent, manipulative, or deceptive conduct, or in making any false statements or material omissions of fact?
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Yes
No
Have you ever had an authorization to act as an attorney, accountant or federal contractor that was revoked or suspended?
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Yes
No
Have you been notified, in writing, that you are now the subject of any regulatory complaint or proceeding?
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Yes
No
Are you named in any pending investment-related civil action?
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Yes
No
Have you ever been named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that you were involved in one or more sales practice violations?
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Yes
No
Have you ever voluntarily resigned, been discharged or permitted to resign after allegations were made that accused you of violating investment-related statutes, regulations, rules, or industry standards of conduct?
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Yes
No
Within the past 10 years have you or any organization that you controlled made a compromise with creditors, filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition?
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Yes
No
Has a bonding company ever denied, paid out on, or revoked a bond for you?
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Yes
No
Do you have any unsatisfied judgments or liens against you?
*
Yes
No
Do you have any tax liens (e.g. IRS, franchise tax, etc.) outstanding or resolved yet undisclosed to the firm?
*
Yes
No
If you answered "Yes" to any of the above questions, please explain here.
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Attestation
I attest that the information provided above is true and accurate to the best of my knowledge.
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Acknowledge and Agree
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