Additional Information Required by Section 130.810(b)(3)-(5) and (7) of the Rules for Registration as a Securities Dealer Illinois Secretary of State Securities Department 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 217-782-2256 Name of Firm: 1. CRD Number: Designated Principal(s) to be Responsible for the Offer or Sale of Securities in Illinois: A. Applicant understands that each dealer registered in the State of Illinois must have at least one examination-qualified principal who is responsible for the offer or sale of securities and the supervision of each registered salesperson servicing Illinois customer accounts. Each designated principal must have passed the qualifying examinations as set forth in Section 130.822 of the Rules. B. Applicant understands that each designated principal who offers for sale or sells securities in the State of Illinois must be registered as a salesperson under Section 8.C of the Illinois Securities Law of 1953. C. Name, CRD Number(s) and qualifying examination(s) for each person who will be responsible for the offer or sale of securities and the supervision of salespersons in the State of Illinois: Name of Designated Principal Name of Designated Principal Name of Designated Principal CRD Number CRD Number CRD Number Qualifying Exams Qualifying Exams Qualifying Exams D. Applicant undertakes to amend this list and file the amendment with the Illinois Securities Department no later than 10 business days after any change of any designated principal. 2. Net Capital Requirement Under Section 130.826 of the Rules: A. Applicant has a minimum net capital requirement of $ of 1934, and affirms that it will maintain such minimum net capital. as set forth in Rule 15c3-1 under the Securities Exchange Act B. Applicant uses the following method to calculate net capital (check applicable box): o Aggregate Indebtedness Method o Alternative Method C. Applicant is subject to maintaining the special reserve account for the benefit of customers as required in Rule 15c3-3 under the Securities Exchange Act of 1934 (check applicable box): o Yes o No D. Applicant clears its public customer accounts in the following manner (check applicable box): o 1. Self-Clearing o 2. Omnibus-Clearing Agreement(s) with: o 3. Introducing-Clearing Agreement(s) with: o 4. Other (explain): o 5. Not Applicable (type of product): E. If applicant is engaged solely in the sale of direct participation programs, mutual funds or other limited securities business, applicant will limit its securities activities in Illinois to the sale of (type of product): All customer funds and securities will be promptly forwarded to the appropriate accounts and will at no time be held by the applicant. F. Applicant undertakes to notify the Illinois Securities Department in writing within 24 hours, as provided in Section 130.828 of the Rules, if applicant fails to maintain the required minimum net capital. Printed by authority of the State of Illinois. November 2015 -- 100 -- SEC 311.3 American LegalNet, Inc. www.FormsWorkFlow.com 3. Request for Waiver of Records to be Maintained in Illinois -- Applicant will not maintain its principal office in the State of Illinois and requests a waiver of Section 130.825 of the Rules under the Illinois Securities Law of 1953. A. Applicant affirms that the records pertaining to the offer or sale of securities to or purchased from Illinois residents will be maintained separately and in such a manner that they can be made available upon request by the Illinois Securities Department within 72 hours. Name, Address and Telephone Number where Illinois records will be maintained: Name Telephone Number Address City, State, ZIP B. In the event such records are maintained in a location outside the principal office of the dealer, the relationship to the dealer is: C. Applicant understands that if it is a Corporation and opens a branch office in the State of Illinois, as defined in Section 130.280 of the Rules, the applicant must file as a Foreign Corporation with the Department of Business Services, Office of the Secretary of State. 4. Affidavit of No Sale of Securities in Illinois -- Applicant hereby applies for registration as a dealer to engage in the sale of securities in the State of Illinois. Applicant hereby certifies that (check A or B): o A. 1. Neither applicant nor any of its representatives has sold or entered into any agreement to sell any securities to any Illinois residents; and 2. Neither applicant nor any of its representatives will engage in the business of offering or selling securities to Illinois residents until said firm is registered to do so with the Illinois Securities Department. o B. Applicant has engaged in the offer or sale of securities to Illinois residents. All information relating to said sales is attached, including the exemption under which Illinois residents' accounts have been or are being serviced, if applicable. Applicant acknowledges the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Illinois Securities Department may result in enforcement action. 5. Salesperson(s) to be Registered Under Section 8.C: A. Applicant understands that each registered dealer in the State of Illinois must have at least one salesperson registered under Section 8.C of The Illinois Securities Law of 1953, except a registered dealer who effects trades solely as a clearing dealer on behalf of other dealers. Each salesperson to be registered in Illinois must have passed the qualifying examinations as set forth in Section 130.832 of the Rules. B. Applicant understands that each designated principal who offers for sale or sells securities in the State of Illinois must be registered as a salesperson under Section 8.C of the Act. C. Applicant will effect trades solely as a clearing dealer on behalf of other dealers in the State of Illinois: o Yes o No -- If no, Complete item D. D. Name and CRD Number(s) of at least one or more person(s) to be registered as salesperson(s) in the State of Illinois for which Form U-4 and the filing fee are being submitted to the Financial Industry Regulatory Authority (FINRA) through the CRD System. The dealer registration will not be granted until the Illinois Securities Department has verified that Form U-4 has been filed and the filing fee paid to the FINRA. Name of Salesperson Name of Salesperson Name of Salesperson Name of Salesperson CRD Number CRD Number CRD Number CRD Number E. Applicant underta