Investment Adviser Representative Examination Affidavit 1. Name: 2. Address: 3. Have you obtained a passing score on the Uniform Investment Adviser Law Examination (Series 65 examination)? Yes No 4. Have you obtained a passing score on the General Securities Representative Examination (Series 7 examination) and the Uniform Combined State Law Examination (Series 66 examination)? Yes No 5. Were you registered as an investment adviser representative in any jurisdiction in the United States on July 1, 2000 and for two (2) consecutive years prior to that date? Yes No 6. Have you ever been found to have violated any state or federal securities law? Yes No If the answer to this question is "yes", provide a detailed description of the findings on a separatesheet. 7. If you hold one or more of the following professional designations, check each that applies: Certified Financial Planner (CFP) awarded by the International Board of Standards and Practices for Certified Financial Planners, Inc. Chartered Financial Consultant (ChFC) awarded by the American College, Bryn Mawr, Pennsylvania. Personal Financial Specialist (PFS) awarded by the American Institute of Certified Public Accountants Chartered Financial Analyst (CFA) awarded by the Institute of Chartered Financial Analysts. Chartered Investment Counselor (CIC) awarded by the Investment Counsel Association of America, Inc. I, ______________________________, hereby depose and say that the information provided herein is true and accurate. ______________________________ Signature SWORN TO AND SUBSCRIBED before me this _____ day of _________________, 20___ ______________________________ Notary My commission expires on: ____________________