FIS 0532 (6/01) Office of Financial & Insurance Services Division of Securities Business History One of these forms is to be completed by each Officer and Director Broker-Dealers / * Issuers name Name of Individual Present Home Address Position with above Will you be active full time or part time in affairs of above? *If issuer, present holdings of securities of this issuer *If issuer, amount of this issue you intend to purchase What will be your total annual salary or compensation Date of Birth Place of Birth U.S. Citizen YES NO / / Education (State fully amount of technical or professional training, if any, and where obtained) Give below or attach a chronological accounting of your time from completion of formal education to the present time. Do not list positions held less than six months. If inactive at any time for more than six months, state when, for how long, and for what reasons. Beginning Ending Business of Position Name and Address of Employer Date Date Employer HeldOur Web address is http://cis.state.mi.us/ofis This form is issued under Act 265, PA 1964, as amended. You mustOur toll free number is 1-877-999-6442 file this form as required under Section 304 of the Act. RETURN COMPLETED APPLICATION TO: Division of Securities P.O. Box 30701 Lansing MI 48909-8201 >>>> 2ALL QUESTIONS MUST BE ANSWERED Have you ever been adjudicated as bankrupt? YES NO Have you ever been indicted or arrested or arraigned or tried for or convicted of a felony? YES NO Have you ever been refused any license or registration by this or any other governmental agency? YES NO Or after such license or registration was granted, was same ever suspended or revoked? YES NO Or has application for license or registration ever been withdrawn? YES NO Is there any litigation pending against either yourself or any firm or company of which you are now a partner or an officer or director? YES NO Were you ever a partner, managing member, director, or officer of any firm or company which was adjudicated as bankrupt or for which a receiver was appointed either during the time or within one year after you were so connected therewith? YES NO Was any firm or company, while you were a partner, managing member, an officer, or director thereof, refused a license or registration or permission to sell securities by this or any other governmental agency? YES NO Or after such license or registration or permission was granted was same ever suspended or revoked? YES NO (If your answer to any of the foregoing questions is "yes", explain the circumstances fully on a separate sheet.) Name the corporations or businesses with which you have been identified in the past, either as an officer, director, partner, m ember, owner, or as an executive. Are you at present a partner, managing member, officer, or director in any otherIf so, state name, address, and positions held in each. business? YES NO Name Address Position I, of the City of , State of , oflawful age, being first duly sworn, depose and say that I have read the above and know the contents thereof and that the statements therein contained are true. (Signed) State of , County of Subscribed and sworn to before me this day of , . Notary Public My Commission expires