STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 10-17) (Department of Business Oversight Use Only) DEPARTMENT OF BUSINESS OVERSIGHT Fee Paid $ File No. Receipt No. PRE-LICENSE AMENDMENT NO. POST-LICENSE AMENDMENT NO. The application must be TYPEWRITTEN and accompanied by an application fee of $1,400. The application (together with the fee payable to the Commissioner of Business Oversight must be filed only in the Sacramento Office of the Department of Business Oversight. Special Instructions: Any amendment to this application for licensure under the Capital Access Company Law shall be made by a verified pre-license or post-license amendment to the application. A pre-license amendment is required for an amendment to the application prior to licensure; a post-license amendment is required after licensure. An amendment is made by filing the completed -license or post-license amendment number entered, attaching the pages of that part of the application (including the exhibits) that are revised or changed, and end of this application.) 1.Name of Applicant: Fictitious Business Name: 2.List the place or places of business at which Applicant will engage in licensed activity. Indicateprincipal place of business and branch or other office locations: (Attach a separate sheet, ifnecessary.)(Number and Street) (City) (County) (State) (Zip) (Name of person in charge of business location) 3.Applicant is organized and will do business as (check as applicable): a corporation a limited liability company a partnership a limited partnership trust other (please specify) [The application continues on the following, separate pages.] 4.Complete the following:Applicant was organized on .(Date) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 10-17) Page 2 of 10 The FULL first, middle (if no middle name, so indicate) and last name, and complete business address MUST be given for each person named below: (Attach additional sheets, if necessary.) General Partners: (Name) (Business Address) (Name) (Business Address) (Name) (Business Address) President/Chief Executive Officer: (Name) (Business Address) Executive Vice President/Vice President: (Name) (Business Address) Secretary: (Name) (Business Address) Treasurer/Chief Financial Officer: (Name) (Business Address) Other Principal Officers: (Name and Title) (Business Address) (Name and Title) (Business Address) (Name and Title) (Business Address) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 08-13) Page 3 of 10 Director(s): (Name) (Business Address) (Name) (Business Address) (Name) (Business Address) Manager(s)/Member(s) [i.e., a manager member of an association, or a manager appointed or elected by the members of a limited liability company]: (Name) (Business Address) (Name) (Business Address) (Name) (Business Address) Trustee(s): (Name) (Business Address) (Name) (Business Address) (Name) (Business Address) Employees who have access to or responsibility for funds held by the applicant: (Name and Title) (Business Address) (Name and Title) (Business Address) (Name and Title) (Business Address) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 10-17) Page 4 of 10 5. a. b. 6. Any person (other than those persons listed above) that owns or controls, directly or indirectly, the power to direct, or cause the direction of, the management and policies of ase provide sufficient information to identify the individual(s) in positions of management in, or who own or control, the corporation or business entity. (E.g., the name and business address of the officers, directors, partners, etc.) (See Corporations Code Sections 28035 and 28036): (Name) (Business Address) (Name) (Business Address) Provide the following information for the investment adviser(s) who will make recommendations to the applicant with respect to the investment of funds. (Name) (Business Address) (Name) (Business Address) (Name) (Business Address) Provide the following information for each investment adviser: 1.Is the investment adviser registered under the Investment Advisers Act of 1940? No. Explain why and cite the appropriate statutory authority. (E.g., the investment adviser is exempt from registration under Section 203(b)(1) of the Investment Adviser Act of 1940.). 2.Is the investment adviser licensed by the State of California? No. Explain why and cite the appropriate statutory authority. (E.g., the investment adviser is exempt from licensure under Section 25202 of the Corporate Securities Law of 1968.) a. Furnish the File Number(s) of any other Department of Business Oversight currently held by applicant or affiliates of the applicant:b.Furnish the license number(s) and description of any state or federal licenses held bythe applicant. (E.g., a California rea . American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 08-13) Page 5 of 10 7. Note: If you DO NOT designate a fiscal year end, the Department of Business Oversight willrecord your fiscal year end as December 31.8.If any person other than the applicant makes or keeps any of the books, accounts, or otherrecords of the applicant, provide the following information:(Name) (Business Address) (Relationship to applicant) 9.The following items MUST BE provided as Exhibits to the application:EXHIBIT A. A statement of financial solvency supported by an audited financial statement dated not more than 90 days from the date this application is filed with an unqualified opinion prepared by an independent certified public accountant in accordance with generally accepted accounting principles reflecting the required minimum tangible net worth of $250,000, the minimum $5,000,000 to invest, years from the date of licensure. EXHIBIT B. A copy of the fidelity bond (including any riders). A certified copy of the bond and any riders shall be filed with the Commissioner within 10 days of its execution. [See Rule 280.400.] EXHIBIT C. For each person named in Item 4 of this application, please furnish the following: 1.A Statement of Identity and Questionnaire*,2.Fingerprint Card*, and3. Trustees, and Employees of a Capital Access Company*. [See Rule 280.153.]*These documents shall be treated by the Department of Business Oversight as beingreceived in confidence pursuant to paragraph (4) of subdivision (d) of Section 6254 of theGovernment Code.EXHIBIT D. A detailed plan of business that includes at a minimum the following items: 1.Describe in sufficient detail the business activities of the applicant, including but not or purchase securities of small business firms. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT APPLICATION FOR LICENSE UNDER THE CAPITAL ACCESS COMPANY LAW DBOCACL 280.151 (Rev. 10-17) Page 6 of 10 2. 3. 4. 5. 6. 7. Information as to the education, financial condition and business experience, and criminal convictions of the following: a. Any person that owns or controls, directly or indirectly, 10 percent or more ofany class of stock or other voting securities of the applicant.b.Any person that controls, directly or indirectly, the election of 25 percent or moreof the members of the board of directors, executive committee, or other policycommittee of the applicant.c.Any person or entity that can control the management of the applicant.A description of any disciplinary actions filed against any other license under which the applicant conducts its business. A description of any adverse judgments entered in court actions filed against the applicant based upon allegations of fraud, misrepresentation, or dishonesty in the A listing of all material judgments