THE COMMONWEALTH OF MASSACHUSETTS SECRETARY OF THE COMMONWEALTH SECURITIES DIVISION ONE ASHBURTON PLACE BOSTON, MASSACHUSETTS 02108 SECTION 202(a) AFFIDAVIT FOR AN INDIVIDUAL WAIVING AUTOMATIC AGENT REGISTRATION This affidavit is made and filed with the Office of the Secretary of the Commonwealth, Massachusetts Securities Division for the purpose of excepting from the definition of Agent the individual named herein who, otherwise, automally would be registered pursuant to M.G.L. atic c.110A, Section 202(a). _____________________________________ hereby swears or affirms: Name of Affiant 1. I am a/an/the _____________________of _________________________________ Title Name of Broker-Dealer a broker-dealer registered or seeking registration in the Commonwealth of Massachusetts. 2. In that capacity, I do not effect or attempt to effect purchases or sales of securities in the Commonwealth or engage in any other activity which falls within the definition of agent and, will not engage in such activity unless and until such time as I become duly registered as a broker-dealer orent in the Commonwealth and pay to the ag Commonwealth the fee required by Section 202(b) of the Massachusetts Securities Act, M.G.L. c.110A. Signed under the penalties of perjury this __________ day of ___________ _________, 20_____ _________________________________________ Signature of Affiant American LegalNet, Inc. www.USCourtForms.com