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Micro-Grant Application Form

  1. (hereinafter, "Applicant")

  2. (hereinafter, "Applicant Officer")

  3. I, the aforementioned Applicant Officer, hereby certify that none of the executive officers or members of the board of directors of the Applicant: (A) have filed a registration statement that is subject to a currently effective registration stop order entered by any state securities administrator or the SEC within the last five years; (B) have been convicted within the last five years of any criminal offense in connection with the offer, purchase, or sale of any security, or involving fraud or deceit; (C) is subject to any current state or federal administrative enforcement order or judgment, entered within the last five years, finding fraud or deceit in connection with the purchase or sale of any security; or (D) is subject to any current order, judgment, or decree of any court of competent jurisdiction, entered within the last five years, temporarily, preliminarily, or permanently restraining or enjoining the party from engaging in or continuing to engage in any conduct or practice involving fraud or deceit in connection. I further undertake to monitor for any events that constitute a disqualification condition after the date of my signature below, and if any such events occur, I will submit full disclosure of the events resulting in a disqualification condition to the General Counsel in the Office of the Kansas Securities Commissioner.

    Applicant agrees to disengage in any lobbying activity directed at influencing members of the public, (including school officials or other public or private organizations who have an interest in financial education) to urge a negative view of other KSC grantees or agency-sponsored educational programming or activities.

    Applicant further agrees that neither it nor any of its affiliates will directly or indirectly, express (through any form of communication) any statement that might reasonably be construed to be derogatory, critical of the Office of the Kansas Securities Commissioner or any of its employees, agents or other agency-sponsored programs, or be designed to malign, harm, disparage, defame or damage the reputation of the agency, its business or any of its sponsored programming.

  4. Executive Director or CEO Officer

  5. Leave This Blank:

  6. This field is not part of the form submission.