Regulator Membership Application

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Member Information

Title

Date of Birth

Month/Day/Year

Last Name

First Name, Middle Initial

State Agency

Mailling Address

Office City, St Zip

Residential City, St Zip

Office Phone

(555) 123-4567

Fax

(555) 123-4567

Toll Free

(555) 123-4567

Confirm email

Website

Bar Information

State Eligible to Practice

Year Admitted to Practice

State Admitted to Practice

State Bar Number

Additional State Eligible To Practice

Year Admitted to Practice

State Admitted to Practice

State Bar Number

Additional State Eligible To Practice

Year Admitted to Practice

State Admitted to Practice

State Bar Number

Please state if your license to practice law in any jurisdiction has ever been suspended or revoked

Yes

If yes, State(s) suspended or revoked and explanation

Securities Licenses and Arbitration Forum Affiliations

Securities Licenses List

Arbitration Forum Affilitations

Questions	Not_Applicable	Public	Non-Public	Chair
FINRA	Not_Applicable	Public	Non-Public	Chair
AAA	Not_Applicable	Public	Non-Public	Chair
Other	Not_Applicable	Public	Non-Public	Chair

If other, Forum

List all broker licenses, the date each was received, and list all firms you are/were affiliated, and dates. Please submit a current copy of your U-4 (email attachment to piaba@piaba.org; fax (405) 360-2063). Enter N/A if Not Applicable.