Service Bureau Authorization Form

Service Bureau Authorization Form
1. This Service Bureau Authorization Form (this “Authorization”) is between IEX Services LLC (“IEX”), the Subscriber
of the ATS designated below (“Subscriber”), and the Authorized Service Bureau designated below (“Service
Bureau”).
2. This Authorization authorizes the Service Bureau to route orders and any modifications thereto to the ATS on
behalf of the Subscriber.
3. By executing this Authorization, the undersigned Subscriber agrees that it is responsible for all orders using its
MPID entered on the ATS through or by the Service Bureau. The Subscriber also agrees to accept and honor all
trades executed on the ATS as a result of orders routed to the ATS through or by the Service Bureau using the
Subscriber’s MPID, regardless of whether such orders were provided to the ATS in error by the Service Bureau.
4. The Subscriber understands and agrees that it is its sole responsibility to immediately notify IEX in the event that
it wishes to terminate this Authorization.
5. This Authorization is for the term of one (1) year from the date of execution and shall be automatically renewed
on an annual basis unless terminated by any party upon twenty-four (24) hours prior written notice.
6. This Authorization shall be governed by the laws of the State of New York without regard to its choice of law
provisions.
IN WITNESS WHEREOF, the parties have executed this Service Bureau Authorization effective as of the date set forth
below.
[SERVICE BUREAU]:
[SUBSCRIBER]:
IEX Services LLC
________________________
Signature
_________________________
Signature
_________________________
Signature
________________________
Print Name
_________________________
Print Name
_________________________
Print Name
________________________
Title (must be an officer)
_________________________
Title (must be an officer)
_________________________
Title
________________________
Name of Service Bureau
_________________________
Date
_________________________
Date
__________________________
Email Address of Contact Person
_________________________
MPID of Subscriber
IEX Services LLC – v1.1 December/2014
Page 1 of 1