IDAHO DEPARTMENT OF FINANCE SECURITIES BUREAU P.O. BOX 83720 BOISE, IDAHO 83720-0031 APPLICATION FOR RENEWAL OF ISSUER AGENT OR NON-NASD BROKER/DEALER AGENT LICENSE TO BE COMPLETED BY AGENT Pursuant to the provisions of the Uniform Securities Act (2004) of the State of Idaho, the undersigned hereby makes application for renewal of license for issuer agent or broker/dealer agent of (issuer or broker/dealer firm) and in compliance therewith, submits the following information: Name (agent) Social Security No. Residential address If above-named agent has changed their name, please indicate previous name 1. Have you been the subject of any complaint, investigation, administrative or injunctive proceedings, either permanent or temporary, involving securities, insurance or any other financial transaction during the past year?____ If so, explain fully on attached separate sheet to be marked Exhibit I. 2. Have you been convicted of the commission of any crime or is there any action pending other than traffic violations during the past year, or have you been denied the right to sell securities in any other state or been barred from any profession? ____ If so, explain fully on attached separate sheet to be marked Exhibit II. 3. Have you, or any organization owned or controlled by you or in which you were an officer, director or partner, been the subject of any insolvency or bankruptcy proceedings during the past year?____ If so, explain fully on attached separate sheet to be marked Exhibit III. 4. Will you devote full time to the position of agent?____ If answer is "no", attach a letter from your present employer granting you permission to engage as a part time agent if one is not on file with this department. I hereby certify that I have read and knowingly made the foregoing statements and representations and that each and all of such statements and representations are true. (Signature of Applicant) TO BE COMPLETED BY ISSUER (Firm) This is to certify that (agent) is reappointed by (issuer or broker/dealer firm) of (physical address) to act exclusively as agent for the named within issuer or broker/dealer firm in the sale of securities pursuant to the provision of the Uniform Securities Act (2004). Dated this day of , 20 By (Official Signature for Company) Title Note: a Fifty Dollar ($50.00) license fee must accompany each application. License to be mailed to: American LegalNet, Inc. www.USCourtForms.com