Fair Administration and Governance of Self-Regulatory Organizations; Disclosure and Regulatory Reporting by Self-Regulatory Organizations; Recordkeeping Requirements for Self-Regulatory Organizations; Ownership and Voting Limitations for Members of Self-Regulatory Organizations; Ownership Reporting Requirements for Members of Self-Regulatory Organizations; Listing and Trading of Affiliated Securities by a Self-Regulatory Organization

Date Filed
(MM/DD/YY):

OFFICIAL
USE
ONLY

WARNING: Failure to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep accurate books and records or otherwise to comply with the provisions of law applying to the conduct of the applicant would violate the federal securities laws and may result in disciplinary, administrative, or criminal action.

INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE CRIMINAL VIOLATIONS

_ APPLICATION _ AMENDMENT

1. State the name of the applicant:
2. Provide the applicant’s primary street address (Do not use a P.O. Box):
3. Provide the applicant’s mailing address (if different):
4. Provide the applicant’s business telephone and facsimile numbers:
Telephone: _________________________ Facsimile: _________________________
5. Provide the name, title, and telephone number of a contact employee:
Name: ____________________ Title: ____________________ Telephone Number: ____________________
6. Provide the name and address of counsel for the applicant:
7. Provide the date applicant’s fiscal year ends:
8. Indicate legal status of applicant:
_ Corporation _ Sole Proprietorship _ Partnership _ Limited Liability Company _ Other (specify):
If other than a sole proprietor, indicate the date and place where applicant obtained its legal status (e.g. state where incorporated, place where partnership agreement was filed or where applicant entity was formed):
(a) Date (MM/DD/YY): _____________________ (b) State/Country of formation: _____________________
(c) Statute under which applicant was organized:
9. Provide the Internet Web site address at which the applicant’s Form 1 and amendments, as filed with the Commission, may be viewed:

EXECUTION: The applicant consents that service of any civil action brought by, or notice of any proceeding before, the Securities and Exchange Commission in connection with the applicant’s activities may be given by registered or certified mail or confirmed telegram to the applicant’s contact employee at the main address, or mailing address if different, given in Items 2 and 3. The undersigned, being first duly sworn, deposes and says that he/she has executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements contained herein, including exhibits, schedules, or other documents attached hereto, and other information filed herewith, all of which are made a part hereof, are current, true, and complete.
Date: _________________________ ____________________________________
(MM/DD/YY) (Name of applicant)
By: __________________________ ____________________________________
(Signature) (Printed Name and Title)

Subscribed and sworn before me this ______ day of ______________, _______ by ________________________
(Month) (Year) (Notary Public)

My Commission expires _________________County of ___________________State of _____________________

This page must always be completed in full with original, manual signature and notarization.
Affix notary stamp or seal where applicable.

Form 1
Page 2

UNITED STATES SECURITIES AND EXCHANGE COMMISSION