FORM 33-e-1 DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES 1025 Capital Center Drive, Suite 200 Frankfort, KY 40601 1-800-223-2579 APPLICATION FOR RENEWAL OF ISSUER AGENT REGISTRATION In compliance with Section 292.331 of the Kentucky Revised Statutes, the Issuer named below requests renewal of agent registrations for the period of _________________ until _________________. Name of Issuer: _______________________________________________________________________ Street Address: ________________________________________________________________________ City: ___________________________ State: __________________ Zip: _________________________ Contact Person: __________________________________________ Phone: _______________________ On behalf of the Issuer, the undersigned respectfully requests renewal of the registration(s) of the issuer agent(s) listed on this form. In accordance with KRS 292.331(5), by signing below the Issuer affirms either: (a) there have been no material changes in the agent's information since the most recent U4 was submitted to the Division or (b) an updated U4 which discloses all material changes in the agent's information is included with this renewal application. Signed by: __________________________________________ Title: __________________________ *Contact Email Address* (Required) ______________________________________________________ NOTE: Attach a renewal fee check (number of agents x $50.00) to this application. Please make check payable to: Kentucky State Treasurer. (NO PERSONAL CHECKS ACCEPTED) PLEASE LIST BELOW ALL AGENTS FOR WHOM APPLICATION FOR RENEWAL OR REGISTRATION IS REQUIRED. ______________________________________________________________________________ ___SS# AGENT'S FULL NAME BUSINESS ADDRESS____ American LegalNet, Inc. www.FormsWorkFlow.com