The evidence of registration described by Section 4004.104 must:
(1) be in the form the commissioner prescribes; and
(2) state:
(A) the name of the agent or investment adviser representative;
(B) the address of the registered dealer or investment adviser, as appropriate; and
(C) that the person is registered for the current calendar year as an agent of the dealer or as an investment adviser representative of the investment adviser, as appropriate.