SECURITIES AND BUSINESS REGULATION 2 Martin Luther King, Jr. Drive, S.E. Ste 802, West Tower Atlanta, Georgia 30334 (404) 656-3920 http://www.sos.state.ga.us/securities/ KAREN HANDEL Commissioner of Securities DESIGNATED SALESMAN TRAINING CERTIFICATION Georgia Securities Act of 1973, as amended O.C.G.A. §10-5-3(d) and Rule 590-4-2-.15 1. NAME & MAILING ADDRESS OF THE INDIVIDUAL APPLICANT 2. APPLICANT'S CRD NUMBER 3. TELEPHONE NUMBER 4. NAME & MAILING ADDRESS OF THE DESIGNATED DEALER 5. DEALER'S CRD NUMBER 6. NAME OF THE DEALER'S COMPLIANCE OFFICER 7. TELEPHONE NUMBER 8. CHECK NUMBER OF $20.00 FILING FEE ROBERT D. TERRY Assistant Commissioner of Securities CHECK #: 9. EXECUTION AND ACKNOWLEDGEMENTS. We, the undersigned, for the purpose of complying with the Georgia Securities Act of 1973, as amended, certify that the applicant named herein is in compliance with said Act and has completed or has begun and will complete, prior to offering and selling designated securities within or from Georgia, a four month period of training with the designated dealer named above. The designated dealer and the applicant acknowledge that such training included, or will include, the definitions of accredited investor, designated security, blank check offering, designated dealer and established customer [See O.C.G.A. §10-5-2(a)]; the required contents of trade confirmations [See O.C.G.A. §10-5-3(p)]; suitability of customer accounts [See O.C.G.A. §10-5-12(m) (2)]; required risk disclosure document [See O.C.G.A. §105-12(m) (3)]; customer right of rescission [See O.C.G.A. §10-5-12(m) (4)]; required account statement disclosure [See O.C.G.A. 10-5-12(m) (5)]; compensation limits [See O.C.G.A. §10-5-12(n)]; representations as to market price [See O.C.G.A. §10-5-12(o)]; the anti-fraud provisions of O.C.G.A. §10-5-12; the requirement for designated securities to be listed on an approved quotation system [See O.C.G.A. §10-5-12(p)]; civil liability [See O.C.G.A. §10-5-14(h)]; and the criminal penalties for willful violations of the Act [See O.C.G.A. §10-5-24]. The undersigned represents that the information and statements contained herein are true and complete. 10. NAME AND TITLE OF AUTHORIZED OFFICIAL 11. SIGNATURE DATE: 12. NAME AND TITLE OF APPLICANT 13. SIGNATURE DATE: FILING DATE: FOR OFFICE USE ONLY CODE: DOCKET #: EXAMINER: FEE: $ COMPLETED: FORM DST Rev. 1/2007 American LegalNet, Inc. www.FormsWorkflow.com