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 Sales Representative Print or use typewriter except for signature: __________________________________________________________________________________________ (Applicant’s Name—Last, First, Middle) _________________________________________________________________________________________ (Name and Address of Principal-Broker-Dealer or Issuer) I, the undersigned, having been and now appointed as sales representative by and of the above Principal, and for the purposes of renewal registration as sales representative pursuant to section 409.850, RSMo, Missouri Model Commodities Code, do hereby make the following statements, each of which is true and correct: 1. My 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) _________________________________________________________________________________________ (See note A) 3. My statement in prior applications for initial and renewal registrations as agent filed pursuant to section 409.850, RSMo of the Act, are true and correct, except as follows: _________________________________________________________________________________________ (Enter “None” if None) _________________________________________________________________________________________ (See not B) ___________________________________________ __________________________________________ (Date) (Signature of Applicant) 4. Enclosed is a check, draft or money order in the amount of $15.00 made payable to the Director of Revenue, State of Missouri (MO 15 CSR 30-59.030(2)(C)). A. Consent to any dual registration (MO 15 CSR 30-59.020(6)). B. Specify paragragh number and date of prior application as to which corrections are reported. Continue on reverse if necessary. Any documents evidencing the corrections reported in “3”, above. FORM C-16 (2/2005) American LegalNet, Inc. www.FormsWorkflow.com