STATE OF ARKANSAS SECURITIES DEPARTMENT HERITAGE WEST BUILDING, SUITE 300 201 EAST MARKHAM STREET LITTLE ROCK, AR 72201 TELEPHONE: 501.324.9260 FAX: 501.324.9268 INTERNET: www.securities.arkansas.gov FMLA Form 003 PRINCIPALS, PARTNERS, OFFICERS, TRUSTEES, DIRECTORS AND MANAGERS NOTE: PLEASE SUBMIT ORIGINAL FORMS ONLY; THE DEPARTMENT WILL NOT ACCEPT FAXED COPIES. PLEASE RETAIN A COPY FOR YOUR RECORDS. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR COMPLETION. Copy this page as necessary and attach. Applicant/Licensee: AR License Number* *Enter "PENDING" if license number has not yet been issued. Type of Person (Check all that apply) Owner Director Manager Partner Officer Other (Explain) Ownership % Last, First, Middle Name & Title Last First Middle Title Telephone Number SSN Date of Employment Owner Director Manager Partner Officer Other (Explain) Last First Middle Title Owner Director Manager Partner Officer Other (Explain) Last First Middle Title FMLA Form 003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com Effective Date: January 1, 2004 Amended: January 2007