OFR-DA-5-91 ISSUER/DEALER COMPLIANCE FORM INSTRUCTIONS: Portions of this form may be completed electronically by typing in the fields. The signature and notarization must be completed on a printed form. File a scanned copy of the completed printed form through the Regulatory Enforcement and Licensing (REAL) System at https://real.flofr.com along with the issuer/dealer's application for registration. The undersigned applicant as an issuer required to be registered pursuant to Section 517.12(1) or (2), F.S., selling its own securities exclusively through its principals or agents, will comply with the following requirements set forth in Commission Rules: 1. The registered associated persons of said Issuer/Dealer shall primarily perform, or be intended to perform, at the end of the distribution, substantial duties for, or on behalf of, the issuer other than in connection with transactions in securities. 2. SPECIFY WHICH OF THE FOLLOWING IS YOUR INTENT: a. Issuer/Dealer shall register no more than five (5) associated persons, which person will be exempted from the examination requirements. NOTE: REGISTRATION OF MORE THAN FIVE (5) ASSOCIATED PERSONS AT ANY ONE TIME WILL VOID THIS EXEMPTION. b. Issuer/Dealer may register more than five (5) associated persons, all such persons will fulfill the examination requirements. EXECUTION: The undersigned, being first duly sworn, deposes and says that this form is executed on behalf of, and with the authority of said applicant. Dated the day of , ___________ (Name of Applicant) ________________________________ (Type Name of Undersigned) _____________________________________ (Signature of Officer, Partner, Sole Proprietor) Subscribed and sworn to before me this STATE COUNTY ) )ss ) NOTARY PUBLIC ____________________________________ My Commission expires: ________________________________ day of , _____ (NOTARIAL SEAL) OFR-DA-5-91, Issuer/Dealer Compliance Form (Eff. 9/15). Incorporated by Reference in Rule 69W-600.0013, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com