Mississippi Secretary of State Post Office Box 136 Jackson, Mississippi 39205-0136 Telephone (601) 359-1633 CENTRAL FILING OFFICE SUBSCRIBER REGISTRATION FORM AND AGREEMENT Application by commodity broker for registration and access to records of crop and livestock liens filed with the Central Filing Office under the Food Security Act. Subscriber/Registrant Business Name: _________________________________________________________________ Date: ______/______/______ City: ____________________________ State: _________________________ Zip Code: _________________Phone:________________________ Mailing Address: ___________________________________________________________________________________________________________ Contact Person for Subscriber Registrant: _____________________________ Title: __________________________________________________ Email Address (Required for Internet Access): __________________________________________________________________________________ The Secretary of State's Office restricts access to the Central Filing Registry and UCC Image Vault as some images contain Social Security Numbers, Taxpayer ID numbers and other sensitive personal information. Electronic Access is only granted to organizations or persons having a demonstrated business use or need to the information. The information below is requested to assist us in determining your eligibility for electronic access. Redacted copies of UCC documents are also available by filing a UCC Copy request on UCC Form 11. Subscriber/Registrant Type: [ ] Buyer [ ] Commission Merchant [ ] Selling Agent [ ] Other What is your interest in receiving a list of liens? List business purposes: ____________________________________________________________________________________________________________________________ Government agency or professional group that regulates subscriber, if any: ___________________________________________________________ Other professional or trade associations _________________________________________________________________________________________ Type of List/Service Requested: 1. For lists, how listed [ ] Debtor Name [ ] Tax Identification Number 2. [ ] MASTER LIST - All Farm Products for the entire state. (Note internet access is for the entire database and covers all crops and all counties.) 3. [ ] SPECIFIC LIST ­ Selected Collateral: [__ __ __ __] (See Appendix "C") I only want the list from the counties listed below: (See Appendix "B") ____________________________________________________________________________________________________________________ Media for Lists: [ ] Internet Access Master List (Unlimited Standard Reports $100 Annual Fee. Annual subscription renewal required.) Specific List [ ] Paper ($2 per page of report) [ ] Compact Disk ($25 per CD) Lists on paper are prepared only on request. CD's are issued monthly I, the duly authorized representative of the named subscriber do hereby certify that the information above is true and correct. I understand that this subscription service registration may provide access to debtors' Social Security Numbers, Taxpayer Identification Numbers and other sensitive personal information. Subscriber agrees that it will not disclose Social Security Numbers, Taxpayer Identification Numbers and/or other sensitive personal information obtained from the Central Filing Registry, UCC Image Vault or any documents contained therein to any person or other organization without the express written consent of the debtor. Subscriber further agrees to indemnify and hold harmless the Secretary of State's Office and the State of Mississippi for any claims arising out of disclosure of Social Security Numbers, Taxpayer Identification Numbers or other sensitive personal information obtained from the Central Filing Registry or UCC Image Vault and which may be attributable to Subscriber or its employees, agents, or assigns. Name of Subscriber: _______________________________________________________________ By: _______________________________________________________________ SIGNATURE TITLE State of ____________ County of __________ Personally appeared before me, the undersigned authority in and for the said county and state, on this the _____ day of 20___, the within named affiant, who, after being duly sworn, acknowledged that he is the duly authorized representative of the subscriber, and for and on behalf of said subscriber executed the above and foregoing subscription registration form. ____________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com My Commission expires: ______________________________