Nebraska Department of Banking and Finance Bureau of Securities http://www.ndbf.nebraska.gov 1526 K Street, Suite 300 Lincoln, NE 68508-2732 PO Box 95006 Lincoln, NE 68509-5006 (402) 471-3445 Form IAR Designation of Investment Adviser Representatives (firm name) hereby designates the following investment adviser representatives for Nebraska. File a Form U-4, examination proof(s) and a $40 registration fee for each representative listed directly with CRD/IARD. This page may be reproduced if additional space is required. Except for execution, all information must be typed and submitted to the Department. Individual Name Title CRD or SSN Number Qualifying Exams or Professional Designations On behalf of the above-named firm, I certify that the information set forth on this form, including attachments, is true to the best of my knowledge, the firm has reviewed the Form U-4 of each of the above-named representatives, all Form U-4 amendments are filed with CRD/IARD, exams or qualifying professional designations are verified, and to the extent any previously submitted information is not amended, such information is currently accurate and complete. By: _________________________________________________ Authorized Signature Required _________________________________________________ Printed Name __________________________________________ Date __________________________________________ Title Page 1 of 1 Rev. 2/2017 American LegalNet, Inc. www.FormsWorkFlow.com