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 005 STATE LICENSING INFORMATION 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. Applicant/Licensee: AR License Number* *Enter “PENDING” if license number has not yet been issued. Copy this page as necessary and attach. Name & Address of State Regulatory Agency FMLA Form 005 Telephone Number Page 1 of 1 License Number Expiration Date Effective Date: January 1, 2004 Amended: January 2007 American LegalNet, Inc. www.FormsWorkflow.com