Il Form Bb01 – Fill Out and Use This PDF

Application to register with the Office of the Illinois Secretary of State, Securities Department, pursuant to the Illinois Business Brokers Act of 1995.

1.Name of Applicant (if an individual or sole proprietor, state last name, first name and middle name):

2.Social Security Number or F.E.I.N.:

3.Telephone Number:

4.Name under which Business Broker business primarily is conducted if different:

5.Firm’s Main Address (if P.O. Box, must have legal address): Include Addresses of all Branch Offices in Illinois on additional sheet.

Street Address (LEGAL)		Street Address (MAILING, IF DIFFERENT)
City, State, ZIP		City, State, ZIP

6.Contact Person:

Name		Business Telephone Number
Fax Number		E-mail Address

7.Date and Place Applicant obtained Legal Status:

Date of Formation

Place of Formation

Type of Legal Status:

❏Corporation

❏Partnership

❏Sole Proprietorship

❏Limited Liability Company

❏Limited Liability Partnership

8.If Sole Proprietor, full Residence and Social Security Number:

Street Address

Social Security Number

City, State, ZIP

9.If at the time of this filing the Applicant is succeeding to the business of a currently registered Business Broker:

a.Date of Succession:

b.Name of Predecessors:

c.IRS Employer Identification Number:

Printed by authority of the State of Illinois. August 2005 — 200 — SEC 313.1

10.Nature and Place(s) of Business of the Applicant or Employment History (if an individual) for the past 10 years or for the period of existence if less than 10 years:

11.Background Information: For the purposes of this section only, Applicant also includes principals, officers, directors, partners, members, trustees, managers or any similar individual. Mark each question “yes” or “no.” If the answer to any question is “yes,” provide a detailed explanation and/or documentation on an additional sheet.

a.In the past 10 years has the Applicant been convicted of or pleaded guilty or nolo contendre (no contest) in a domestic or foreign court to:

1.A felony or misdemeanor involving: investment, financial, business broker or related business fraud, false statement, or omissions, wrongful taking of property, or bribery, forgery, counterfeiting or extortion:

❏ Yes ❏ No

2.Any felony (other than listed above):

❏ Yes ❏ No

b.Has any domestic or foreign court in the past 10 years enjoined the applicant in connection with investment, financial or business related activity:

❏ Yes ❏ No

c.Has any other federal regulatory agency, any state regulatory agency or foreign financial regulatory authority:

1. Ever found the applicant to have made a false statement or omission, or been dishonest, unfair or unethical?

❏ Yes ❏ No

2.Ever found the applicant to have been involved in a violation of investment, business or financial regulations or statutes?

❏ Yes ❏ No

3.Ever found the applicant to have been a cause of a business broker, investment or financial related business having its authorization to do business denied, suspended, revoked, restricted or otherwise adversely affected?

❏ Yes ❏ No

4.In the past 10 years entered an order against the applicant in connection with an investment, financial or business broker related activity?

❏ Yes ❏ No

5.Ever denied, suspended, revoked or otherwise adversely affected the applicant’s registration or license, prevented it from associating with an investment, financial or business broker related business, or otherwise disciplined it by restricting its activities?

❏ Yes ❏ No

6.Ever revoked, suspended or otherwise adversely affected the applicant’s license as an attorney or accountant?

❏ Yes ❏ No

d.Has any foreign government, court or regulatory authority ever entered an order against the applicant related to financial activity or fraud other than as reported above?

❏ Yes ❏ No

e.Is the applicant now the subject of any proceeding that could result in a “yes” answer to any parts of Section 11?

❏ Yes ❏ No

f.Has a bonding company denied, paid out on or revoked a bond for the applicant?

❏ Yes ❏ No

g.Does the applicant have any material unsatisfied judgements or liens against it? ❏ Yes ❏ No

Printed by authority of the State of Illinois. August 2005 — 200 — SEC 313.1

12.Name, Residence, Business Address and 10-year occupational statement for each principal of the Applicant. (If a Corporation, provide information for all officers, directors or other persons with similar positions. If a Sole Proprietorship, Partnership, Limited

Partnership, Limited Liability Company, Unincorporated Association, Limited Liability Company or any similar form of business organization, provide information for those person(s) who may legally bind the organization. For more space, attach additional sheets.)

13.Name(s), and Social Security Number(s) of all individuals engaged in business brokering on behalf of the business brokerage firm. (Include individuals listed in #12. For more space, attach additional sheets.)

Date	Name of Applicant
	Signature
	Name and Title (type or print)

Printed by authority of the State of Illinois. August 2005 — 200 — SEC 313.1