CITY OF ANYWHERE, USA
Beach Cities Health District
Broker/Dealer Questionnaire
Beach Cities Health District was established in 1955 by the County of Los Angeles under the Local Hospital District Law (Division 23 of Health and Safety Code of the State of California). The District manages an operational portfolio ranging in size from $20 to $30 million which is comprised mainly of U.S. Agency and obligations as well as a portion placed in the California State Treasurer’s Local Agency Investment Fund (LAIF). The District has adopted a written Investment Policy that regulates the standards and procedures used in its cash management activities. A current copy is available on request and should be reviewed prior to completing this form.
Firm Name:
Year Founded:
Corporate office address:
Telephone #s:
Principal, Managing Director or Partner:
Name
Title
Direct phone
E-mail address
Is your firm a broker (does not own securities being offered)?
Is your firm a dealer (does own securities being offered)?
Local office address:
Please attach a bio or resumé of the primary and secondary representatives covering this account, including securities-related employment history, licensing, certificates, complaints, disciplinary action, arbitration, litigation:
Primary Representative:
Name
Title
Direct phone
E-mail address
Secondary Representative:
Name
Title
Direct phone
E-mail address
Provide proof of registration with NASD ( attached ( na
Provide proof of registration with State of California ( attached ( na
Provide proof of Financial Industry Regulatory Authority (FINRA) ( attached ( na
Provide documentation that your firm is qualified under SEC rule 15C3-1 (Uniform Net Capital Rule ( attached ( na
Provide most recent audited financials ( attached ( na
Is your firm is examined by and subject to rules and regulations of:
FDIC ( Yes ( No
SEC ( Yes ( No
NYSE ( Yes ( No
Comptroller of Currency ( Yes ( No
Federal Reserve System ( Yes ( No
List three current comparable public client references (Los Angeles area preferred):
Entity Name
Contact
Address
Phone / E-mail
Entity Name
Contact
Address
Phone / E-mail
Entity Name
Contact
Address
Phone / E-mail
What market sectors are you and your firm currently involved? (Please feel free to provide additional information regarding specialization in any of the following market sectors).
Firm Involvement Broker Involvement
US Treasuries
US Agency Bonds
California State Bonds
Municipal Bonds
Corporate Bonds
Negotiable CDs
Time CDs
CDARS
Repurchase Agreements
Mutual Funds
Other
Has this firm, or the representatives assigned to this account, been subject to a regulatory agency, state or federal investigation for alleged improper, disreputable, unfair or fraudulent activities related to the sale of securities or money market instruments that resulted in a suspension or censure?
( Yes (attached) ( No
Is there outstanding litigation which would materially affect your financial stability?
( Yes (attached) ( No
Do you provide any fixed income research and economic commentary?
( Yes (attached) ( No
Describe the precautions taken by your firm to protect the interests of the public when dealing with a local public entity.
( Attached ( na
Has any client sustained a loss on a securities transaction engendered from a misunderstanding or misrepresentation of the risk characteristic of a financial instrument by your firm?
( Yes (attached) ( No
Please confirm that you are (1) familiar with the Government Code Sections 53600, et seq, and (2) have read, understand and agree to comply with the provisions of Beach Cities Health District investment policy and by signing below.
Name: Signature:
Title: Date:
Name: Signature:
Title: Date:
Name: Signature:
Title: Date:
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