Dual Registration as an Investment Adviser Representative and Salesperson Illinois Secretary of State Securities Department 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 217-782-2256 This form must be completed and filed by the applicant when a person is a registered salesperson of a dealer and applies for registration as an investment adviser representative under Section 8D of The Illinois Securities Law of 1953. 1. Name of each Registered Salesperson of the dealer named below who also has requested to be an Investment Adviser Representative to the applicant: Name of Salesperson Name of Salesperson Name of Salesperson Name of Salesperson CRD Number CRD Number CRD Number CRD Number Name of Investment Adviser Applicant Signature of Officer, Partner or Sole Proprietor Name and Title (type or print) 2. Dealer Acknowledgement -- The undersigned dealer acknowledges that it is aware of the intention of the above-named person(s) affiliated with the applicant named above to become registered in the State of Illinois as an investment adviser representative, and that the dealer consents to and is aware of its supervisory responsibilities and potential conflict(s) of interest inherent in such a situation. Name of Dealer Signature of Officer, Partner or Sole Proprietor Name and Title (type or print) Notice to Dealer: This form must be returned to the applicant to be filed with the Application for Registration as an Investment Adviser Representative. Printed by authority of the State of Illinois. November 2015 -- 100 -- SEC 331.1 American LegalNet, Inc. www.FormsWorkFlow.com