COI - PST Request
Agent Name
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First Name
Last Name
Agent E-mail
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Agent Phone Number
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Area Code
Phone Number
Upload Transaction Documentation
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Name of Issuer
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Name of Buyer
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Name of Seller
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Anticipated Transaction Date
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Month
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Day
Year
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Is this a securities purchase by you or an entity you own or control?
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Yes
No
Is this a securities sale by you or an entity you own or control?
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Yes
No
Are you a manager, director, or officer of the issuer?
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Yes
No
Are you an equity owner of the issuer?
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Yes
No
What is the source of initial and ongoing capital for this business?
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personal assets
bank loan
private offering
equity issuance
debt instrument issuance
Other
Have you solicited or do you intend to solicit any other individuals to invest in this Issuer?
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Yes
No
Anticipated Investment Amount or Account Value
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Do you receive direct or indirect financial compensation as a result of the transaction, whether directly or indirectly (e.g. performance fees, management fees, commission, etc)?
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Yes
No
Selling Compensation for Transaction
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Asset-Based Fee
Referral Fee
Performance Based Fee
Transaction Based Commission
NONE OF THE ABOVE
Other
Will you participate in the execution of the transaction?
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Yes
No
Did you place a securities buy or sell order for the transaction?
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Yes
No
Is there an RMS Selling Agreement in place for this transaction?
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Yes
No
Will you be advising on implementing a financial or asset allocation plan in connection with this transaction?
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Yes
No
Did you make any recommendation regarding the transaction or the issuer's securities?
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Yes
No
Is this transaction in connection to investment advisory services that you are offering?
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Yes
No
Please describe any potential conflict of interest, whether real or perceived, which may occur as a result of this transaction.
Please include any other information you wish RMS to consider during our review of this transaction:
I attest that I am the agent or have been authorized by the agent to complete this disclosure. I have completed this form truthfully and accurately, to the best of my knowledge.
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Sign Date
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Month
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Day
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