investment adviser

Government of the District of Columbia

Vincent C. Gray, Mayor

Department of Insurance, Securities and Banking

William P. White

Commissioner

INVESTMENT ADVISER WORKSHOP REGISTRATION FORM

Regulatory Requirements for

District of Columbia Investment Advisers

Wednesday, November 16, 2011 (8:30 a.m. – Noon)

One Judiciary Square

441 Fourth Street, NW, Room 1114 South

Washington, DC 20001

If not registering online, please fax the completed registration form to the attention of:

Mr. Maurice Goff, Assistant Director, Licensing Division

D.C. Department of Insurance, Securities and Banking

Securities Bureau

810 First Street, NE, Suite 701

Washington, DC 20002

Telephone: (202) 442−4934 • Fax: (202) 442−8661 • Email:

Please respond by November 7, 2011.

Registrant’s Name:

Title:

Company/Organization:

Phone Number:

Email Address:

Reconfirm Email Address:

Firm/CRD #:

THERE IS NO FEE FOR REGISTRATION