FIS 0580 (3/10) Office of Financial and Insurance Regulation Investment Adviser Representative (IAR) Certification and Consent Our firm ___________________________________________________ IA Firm IARD #___________________, (Name of Investment Adviser (IA) Firm) is hereby requesting a waiver of the examination requirements for the IAR listed below. Name of IAR ________________________________ IAR CRD#________________ Date IAR passed S65 or S66 examination _____________________ REMINDER: THERE CANNOT BE A BREAK IN IAR EMPLOYMENT OF MORE THAN TWO YEARS. IAR’s Employment Dates IAR’s Employers and job duties at each employer (Attach additional pages as needed) (since exam was taken) (since exam was taken) _______________________ ________________________________________________________________ _______________________ ________________________________________________________________ _______________________ ________________________________________________________________ I, __________________________________, certify that I have been employed or engaged by one or more IA firms performing services for which IAR registration is required under the Act without a break in service lasting more than two years since I passed the Series 65 or the series 66 examination. After diligent review of records and information available, I further certify that the above material information is true and accurate to the best of my knowledge, information and belief, and I agree to entry of an order and imposition of a fine if OFIR determines that the information is not true and accurate. I have also read the Fourth Transition Order issued on March 11, 2010 and consent to all penalties to be assessed if false, inaccurate or misleading information is provided. IAR Signature_________________________________________________________ Date_________________ I, __________________________________, certify that the IAR identified above has been employed or engaged by one or more IA firms performing services for which IAR registration is required under the Act without a break in service lasting more than two years since he/she passed the Series 65 or the series 66 examination. After diligent review of records and information available, I further certify that the above material information is true and accurate to the best of my knowledge, information and belief, and I agree to entry of an order and imposition of a fine if OFIR determines that the information is not true and accurate. I have also read the Fourth Transition Order issued on March 11, 2010 and consent to all penalties to be assessed if false, inaccurate or misleading information is provided. Chief Compliance Officer of IA Firm Signature________________________________ Date_________________ I represent that I, _______________________________, am authorized to execute this IAR Certification and Consent on behalf of the IA Firm identified above and certify that the IAR identified above has been employed or engaged by one or more IA firms performing services for which IAR registration is required under the Act without a break in service lasting more than two years since he/she passed the Series 65 or the series 66 examination. After diligent review of records and information available, I further certify that the above material information is true and accurate to the best of my knowledge, information and belief, and I agree to entry of an order and imposition of a fine if OFIR determines that the information is not true and accurate. I have also read the Fourth Transition Order issued on March 11, 2010 and consent to all penalties to be assessed if false, inaccurate or misleading information is provided. IA Firm Owner or Officer Signature_________________________________________ Date_________________ RETURN COMPLETED FORM TO THE OFFICE OF FINANCIAL AND INSURANCE REGULATION Office of Financial and Insurance Regulation Securities Section P.O. Box 30701 Lansing, MI 48909-8201 Authority: PA 551 of 2008. This form is mandatory pursuant to the Fourth Transition Order No. 10-026-M. American LegalNet, Inc. www.FormsWorkFlow.com