Application is hereby made for registration as futures commission merchant for the calendar year ending December 31, 19 pursuant to requirements of the Commodity Exchange Act. Enclosed is remittance payable to the Commodity Exchange Authority, USDA, in the amount of $. to cover the prescribed fee. This consists of $30.00 for the principal office plus $5.00 each for domestic branch offices and each correspondent and agent operating within the United States. 3. Check only (a) or (b) not both: (a) Check here if you are applying for registration as a futures commission merchant under section 1.31a of the regulations; i.e. you will transmit all customers' commodity futures orders, funds, securities, and property to another futures commission merchant for execution or clearance, and the latter will render an accounting to your customers. Where will your general business records and those provided by section 1.37 be kept? (No. Street and Room Number) (City, State and Zip Code) (b) Check here if you are applying for registration as a futures commission merchant under section 4d(2) of the Commodity Exchange Act, as Amended, i.e. you will keep records covering your customers' commodity accounts and funds segregated for such customers. Where will your general business and those commodity records provided under sections 1.20 through 1.37 inclusive be kept? 6. (a) To be completed only if applicant or registrant is a CORPORATION OR OTHER FORM OF ORGANIZATION (EXCLUDING A PARTNERSHIP) NAME OF EACH OFFICER AND DIRECTOR. LIST TITLE AND INDICATE DIRECTOR BY ASTERISK ADDRESS (See instruction C) DATE AND PLACE OF BIRTH AND SOCIAL SECURITY NUMBER (See Instruction C) Continued FORM 2-R MAY 71 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE. U.S. DEPARTMENT OF AGRICULTURE APPLICATION FOR REGISTRATION FORM APPROVED INSTRUCTIONS: This application should be typewritten or printed. Send one copy to the nearest regional office of the Commodity Exchange Authority, U.S. Department of Agriculture, and retain a duplicate for your files. If additional space is needed, use an attachment and refer to corresponding item on form. If you have been previously registered with the Commodity Exchange Authority, answers to certain items on this application have been preprinted. Check any preprinted answers for accuracy and completeness. Where preprinted answers are inaccurate or incomplete make changes or additions on the application form; if sufficient space is not available, use an attachment to the form. See that the form is completed, dated, and signed. Enter Below: 1. NAME 2. BUSINESS ADDRESS (Incl. Rm. No., City, State, and Zip Code) DATE OF BIRTH (Month, Day & Year) RESIDENCE ADDRESS PLACE OF BIRTH (City & State or Country) SOCIAL SECURITY NUMBER pursuant to the requirements of Application is hereby made for registration as floor broker for the calendar year ending December 31, 19. the Commodity Exchange Act. Enclosed is remittance in the amount of $15, payable to the Commodity Exchange Authority, U.S.D.A., to cover the prescribed registration fee. 3. Regulated commodity exchanges of which you are a member. (If membership is pending, so indicate) 4. Name of each principal clearing member through whom transactions in commodities are cleared for your own account, or for any account which you control or in which you have a financial interest. If NONE, check here 5. Name of each principal clearing member for whom you are currently engaged as floor broker. If NONE, check here 6. Have you been the subject of, or currently involved in, any of the following actions which you have not reported to this agency in writing on a previous application or supplemental statement: No (a) Any action (including but not limited to refusal of membership, or suspension or expulsion therefrom) by a commodity or securities exchange or related clearing organization, or by a national securities association? Yes (b) Any action by the United States Securities and Exchange Commission, the securities commission or equivalent authority of any State? No Yes (d) Any conviction involving the handling of any commodity or securities account for any customer? Yes No (e) Any debarment by an agency of the United States from contracting with the United States ? Yes No If the answer to any of the above is yes, furnish details on an attachment to this form. Willful falsification or misrepresentation or willful omission of any material fact required to be stated in this application shall constitute cause for the suspension or revocation of registration and/or prosecution under criminal statutes. CERTIFICATION I hereby represent that, to the best of my knowledge and belief, all statements contained or incorporated in this application are true. You may not legally act as a floor broker for the period covered by this application until you have been notified that you have been registered as a floor broker. 6. Continued (b) Name of each stockholder owning or controlling more than 10 percent of capital stock. If NONE, check here 8. BRANCH OFFICES in the United States in which commodity futures orders are solicited or accepted in the name of the applicant. If NONE, check here 9. COMPLETE ADDRESS OF SUCH BRANCH OFFICE NAME OF MANAGER DATE AND PLACE OF BIRTH AND SOCIAL SECURITY NUMBER (See instruction C) CORRESPONDENTS AND AGENTS (excluding employees, salesmen, and registered representatives) operating within the United States, authorized to solicit or accept commodity futures orders in the name of the applicant. If NONE, check here NAME OF EACH PRINCIPAL ADDRESS OF OPERATION DATE AND PLACE OF BIRTH AND SOCIAL SECURITY NUMBER (See instruction C) 10. Commodity exchanges under Commodity Exchange Authority regulation in which you have membership, or enjoy membership privileges. If NONE, check here REGULATED COMMODITY EXCHANGE (Designate by asterisk each exchange in which you are a clearing member) PERSON WHOSE MEMBERSHIP IS CBT U.S. GOVERNMENT PRINTING OFFICE: 1970 388-587 11. Dave you or any general partner, officer, holder of more than 10 percent of the capital stock, any person particip/Den fa ladarang your business or any of your offices, or any person authorized to solicit or accept commodity futures or ther C ne boca subject to or are currently involved in any of the following actions which you have not reported in writing to time. cency, on a previous application or supplemental statement: (a) Any action (including but not limited to refusal of membership, or suspension or expulsion therefrom) by a commodity or securities exchange or related clearing organization, or by a national securities association? ................. (5) Any action by the United States Securities and Exchange Commission, the securities commission or equivalent authority of any State? (c) Any conviction of a felony ? (4) Any conviction involving the handling of any commodity or securities account for any customer? (e) Any debarment by an agency of the United States from contracting with the United States? () Any action involving either voluntary or involuntary bankruptcy proceedings? ................. If answer to any of the above is yes, furnish details below or on an attachment to this form. ut falsification or misrepresentation or willful omission of any material fact required to be stated in this application or racat of financial condition or supporting schedules shall constitute cause for the suspension or revocation of registration a /or prosecution under criminal statutes. CERTIFICATION We (1) hereby represent that, to the best of our (my) knowledge and belief, all statements contained or incorporated in this application are true. NAME OF APPLICANT DATE NAME AND TITLE (Partner, Corporate Officer, Sole Propriet..) DEPARTMENT OF COMMERCE Subcommittee Analysis The Department of Commerce maintains a large number of data banks but provided responses for only eight, all computerized. The agency claims that only these eight data banks contain information on individuals; of the eight, three maintain information on individuals not of a "personal" nature, according to the Department. Thus, for only five of its many data banks did the Department of Commerce provide answers to the full questionnaire. I. Index Title No questionnaire answers: A. Directory of registered patent attorneys and agents (computerized). B. Patentee index file (computerized)... Description: (1) Purpose; (2) Contents (1) A list of all attorneys. (2) Admitted to the Patent Office practice. (2) Name, assignee, invention patent number for all in- C. Foreign investment financial data file (1) NG.. (computerized). Questionnaire fully answered: D. Uniform ADP system for personnel management (computerized). E. Decennial census (computerized).. F. Seafaring personnel (computerized)... (2) Data on companies and individuals owning 10 percent (1) Commerce administration. (2) Identification and employment data on Commerce em ployees. (1) Enumeration.. (2) Information across a broad spectrum for most citi- (1) "Evaluation of seafaring workforce". (2) Identification data, including USCG documentation G. Merchant Marine Academy students (1) "Current employment records of graduates from various classes" said to be "normal practice of (2) Identification, employment, merchant marine and H. National Defense Executive Reserve (1) Presently, to disseminate information to members of the Reserve; in emergency to assign members to (2) Identification, education, area of expertise, emergency II. Nature of Material Submitted Subjects NG NG NG 33, 100 204, 000, 000 (1970) 117,900 (1968) 13,000 1,500 The department failed to submit responses for three data banks which in their judgment did not include "personal" information. One of the omitted systems, however, contains information about the financial holdings abroad of some individuals, data that by most standards would be considered "personal." In addition, the Department submitted no response at all for unnumbered data banks within the Bureau of Census, because they contained no data on individuals. For the data banks which the department thought required a response, their answers are adequate. The date of the response was October 1970, but no new programs were planned at that time, so no update seems necessary. |