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) Ownership % Last, First, Middle Name & Title Owner Middle Partner Date of Employment First Manager SSN Last Director Telephone Number Title Officer Other (Explain) Owner Last Director First Manager Middle Partner Title Officer Other (Explain) Owner Last Director First Manager Middle Partner Title Officer Other (Explain) FMLA Form 003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com Effective Date: January 1, 2004 Amended: January 2007