STATE OF NEBRASKA BUREAU OF SECURITIES - DEPARTMENT OF BANKING AND FINANCE APPLICATION FOR REGISTRATION AS AGENT UNDER AN ISSUER-DEALER The undersigned hereby makes application for registration as an Agent in securities within the State of Nebraska. The facts herein stated are true and constitute a fair and complete statement of all material facts relating to this applicant. 1. Name of applicant 2. Social Security Number 3. Home address 4. Home phone number 5. Name of firm 6. Business address 7. Business phone 8. Date of employment 9. Educational History: NAME AND ADDRESS OF INSTITUTION (STREET, CITY, STATE, ZIP CODE) 10. FROM MO. YR. TO MO. YR. DID YOU GRADUATE DEGREE Employment history: The following is a complete, consecutive statement of my business history for the past ten years starting with my current position. (All time must be accounted for including self-employment, unemployment, part-time securities, commodities, insurance and real estate, industries or related positions and all military service.) POSITION REASON FOR FULL OR TO NAME OF EMPLOYER AND COMPLETE ADDRESS FROM PART-TIME HELD LEAVING YR. MO. YR. (STREET, CITY, STATE, ZIP CODE) MO. 11. In what states is applicant now licensed or registered to sell securities? 12. In what states has applicant ever been licensed to sell securities? (Specify states, dates of registration) 13. What experience does the applicant have in the sale of securities? 14. List all companies for which the applicant has sold securities. 15. In what manner will the applicant attempt to make sale? (i.e, by telephone, in person. by mail, etc.) IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, ATTACH COMPLETE DETAILS: 16. Are you now, or have you ever been licensed to sell insurance? 17. Are you now, or have you ever been licensed to sell real estate? 18. Have you ever had denied, suspended, or revoked a license, permit, certificate, registration or membership required to engage in securities, commodities, insurance or other business or profession? American LegalNet, Inc. www.USCourtForms.com 19. Are you now, or have you ever been suspended, expelled, fined, barred, censured or otherwise disciplined by an employer in a securities, commodities, insurance or real estate industry? 20. Have you ever been charged with fraudulent acts or violations of any laws in connection with the sale of securities? 21. Has the applicant ever been a subject in connection with a formal complaint, proceeding or investigation brought by the National Association of Securities Dealers, Securities and Exchange Commission or any other state for violations of their securities laws? ... 22. Has any permanent or temporary injunction been entered against you or any broker-dealer, insurer, investment advisor or commodities firm with which you were associated in any capacity at the time such injunction was entered? .................................... 23. In your previous business connections or employment, have you ever been: a. a subject of a major complaint or legal proceeding or, ................................................................................................................. b. discharged or requested to resign by an employer because of dishonest or unethical acts alleged to have been committed by you ................................................................................................................................................................... 24. Are you currently bonded? If yes, specify insurance co. and amount ................................................................................................... 25. Has applicant ever been refused a surety bond? ................................................................................................................................... 26. Has a surety company ever paid out any funds on your coverage or cancelled your bond? ................................................................ 27. Have you ever been: a. Arrested or indicted for any felony or misdemeanor involving the purchase, sale, or delivery of any security, or arising out of the conduct of the business of a broker-dealer, fiduciary, investment company, investment adviser, underwriter, bank, trust company, insurance company or other financial institution, or involving any crime in which violence or threats of violence against any person, dishonesty, the wrongful taking of any property, or any manner of fraud was a factor, or involving conspiracy to commit any of the foregoing? .................................................................................................................... b. Convicted of, or pleaded nolo contendere to, any felony or any misdemeanor, except minor traffic offenses? ......................... 28. Are you currently the subject of an unsatisfied judgement or lien? ........................................................................................................ 29. Are you currently engaged in any other business, either as a proprietor, partner, officer, director, trustee, employee or otherwise? ... THE FOLLOWING SHOULD BE READ VERY CAREFULLY BY THE APPLICANT 1. I hereby certify that I have read and understand the foregoing statements and that my responses are true and complete to the best of my knowledge. 2. To induce the Nebraska Securities Bureau, with which I am filing this application to receive and consider it: A. B. I agree that any decision of the Bureau as to the results of any examination(s) that I may be required to pass will be accepted by me as final; (1) I understand that I am not authorized to sell, or offer for sale, any securities until I have received my license or registration certificate or any official notification of its effective date; (2) I understand that I am to sell only those securities authorized by my employer. American LegalNet, Inc. www.USCourtForms.com C. I agree to abide by the Statute(s), Constitution(s), and Rules as any of the foregoing are amended from time to time of the State of Nebraska and the Nebraska Securities Bureau, with which I am filing this application; D. If I shall violate or be charged with the violation or possible violation of any Statute, Rule or Constitution of with which I am filing this application, I agree to be subject to and abide by the penalties of the Statute(s), Constitution(s), or Rules of the Securities Bureau and the State of Nebraska. 3. Further, and in consideration of the securities organization receiving and considering this application, I submit myself to the jurisdiction of such organization. 4. I, , the undersigned applicant do solemnly swear that the answers to the above questions and the statements herein made are true, and that I have not herein made any statement, which is at this time in the light of the circumstances under which it is made, false or misleading in any material respect. 5. I, the undersigned, for the purpose of complying with the laws of the State of Nebraksa relating to the registration or sale of securities hereby irrevocably appoint the Director of Banking and Finance, or his successors in office, my attorney in said State upon whom may be served any notice, process or pleading in any action or proceeding against me arising out of or in connection with the offer or sale of securities, or out of the violation or alleged violation of the aforesaid laws of said State; and I do hereby consent that any such action or proceeding against me may be commenced in any court of competent jurisdiction and proper venue within said State by service of process upon said appointee with the same effect as if I was a resident in said State and had lawfully been served with process in said State. It is requested that a copy of any notice, process or pleading served hereunder be mailed to me at my residence. Date Signature of Applicant Date Signature of Witness (Witness must be either a partner of the firm, officer of the corporation, or authorized employee. Please indicate which). (NOTARIZATION OF APPILICANT'S SIGNATURE) STATE OF ) ) SS: County ) Subscribed and sworn before me this day of , 19 . Notary Public THE FOLLOWING MUST BE COMPLETED ONLY BY A DESIGNATED OFFICER OF THE ISSUER-DEALER. To the best of my knowledge and belief and the applicant at the time of approval will be familiar with the statute(s), constitution(s), and rules of the State of Nebraska and the Nebraska Securities Bureau with which this application is being filed, and the rules governing registered persons, and will be fully qualified for the position for which application is being made herein. I agree I will not employ the applicant in the capacity stated herein without first receiving the approval of the Nebraska Bureau of Securities, which is required by law. This firm has communicated with all the previous employers of the applicant during the past three years, as set forth on the following page: American LegalNet, Inc. www.USCourtForms.com NAME AND POSITION OF EMPLOYED PERSON CONTACTED EMPLOYER FROM/TO CONTACTED BY PHONE LETTER OR INTERVIEW In addition, I have taken appropriate steps to verity the statements contained in this application and to inquire into the past record and reputation of the applicant. THE ACTS OF THIS EMPLOYEE IN THE COURSE OF HIS/HER EMPLOYMENT OR WHAT MIGHT REASONABLY APPEAR TO BE IN THE COURSE OF HIS/HER EMPLOYMENT IN CONNECTION WITH THE OFFER AND SALE OF ANY SECURITY SHALL BE CONSIDERED AS OUR ACTS AND BIND US FOR ANY FRAUDULENT MISREPRESENTATION OR OMISSION IN CONNECTION WITH THE OFFER OR SALE OF ANY SECURITY. Date Print Name of Issuer- Signature of Issuer-dealer officer Name of Issuer-dealer dealer officer & title List three persons as general references for the agent-applicant American LegalNet, Inc. www.USCourtForms.com