Robin Carnahan Secretary of State State of Missouri Securities Division • 600 W. Main • PO Box 1276 Jefferson City, MO 65102 Application for Renewal Registration of Agent Print or use typewriter except for signature: (Applicant’s Name—Last, First, Middle) (Social Security Number) (Name and Address of Principal-Broker-Dealer or Issuer) (Issuer’s Contact Person) (Telephone No. of Contact Person) I, the undersigned, having been and now appointed as agent by and of the above Principal, and for the purposes of renewal registration as agent pursuant to section 409.4-406(d), RSMo Cumulative Supp. 2006, do hereby make the following statements, each of which is true and correct: 1. Applicant’s current address is (Residence) (Business) 2. I am not and will not be representing more than one broker-dealer or issuer except as follows: (Enter “None” if None) 3. (See MO 15 CSR 30-51.010(3)) My statement in prior applications for initial and renewal registrations as agent filed pursuant to section 409.4-406, RSMo Cumulative Supp. 2006, are true and correct, except as follows: (Enter “None” if None) (Specify Paragraph Number and Date of Prior Application as to Which Corrections are Reported) (Continue on Reverse if Necessary) (Date) (Signature of Applicant) Please include the following with this form: A. Check, draft or money order in the amount of $50.00 made payable to the Secretary of State, State of Missouri, pursuant to section 15 CSR 30-50.030. B. Consent to any dual registration. C. Any documents evidencing the corrections reported in “3”, above. FORM SA-1 (10-07) American LegalNet, Inc. www.FormsWorkflow.com