USE BLACK INK ONLY - DO NOT HIGHLIGHT *020902* Nevada State Business License ROSS MILLER Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov *020902* "Other" Exemption PRINT LEGIBLY OR TYPE ALL INFORMATION ABOVE SPACE IS FOR OFFICE USE ONLY Completing this form DOES NOT relieve you of any statutory or regulatory requirements relating to your business. You may be required to complete a Nevada Business Registration form with the Nevada Department of Taxation and Department of Employment, Training and Rehabilitation. Please check with these and other state/local government agencies for additional licensing requirements. * Asterisks indicate required information. Incomplete forms will be rejected. INSTRUCTIONS: 1. This form is for a business that is not a sole proprietor, partnership or that is not required to organize pursuant to Title 7 of Nevada Revised Statutes and claims an exemption for the State Business License provisions of NRS 76.020. 2. If you are exempt from the requirements of the State Business License pursuant to NRS 76.020 enter the applicable code in Section 4: 001 - A governmental entity 002 - 501(c) Nonprofit Entity 005 - A business whose primary purpose is to create or produce motion pictures 006 - Insurance company doing business pursuant to NRS 680B.020 that does not conduct any business that is not incidental to Title 57 (Div. of Ins. Authority). 3. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, Nevada 89701-4201, (775) 684-5708. 4. The person claiming exemption from the State Business License requirement must sign the application. FORM WILL BE RETURNED IF UNSIGNED. 1* Signature must be that of a responsible party. I declare under penalty of perjury that the information provided is true, correct and complete to the best of my knowledge and belief and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State. I declare that I am exempt from the provisions of the State Business License pursuant to NRS 76.020. Middle (Optional) First Name Suffix Last Name Title X Date Signature of Responsible Party 2 (Required if you have a current Nevada State Business License or had one issued after October 1, 2009) NV Business ID # 3* Entity Name 4* I am exempt from the requirements of the State Business License. Cite exemption code (See instructions for code) 5* Physical Address Physical Street Address 6 8 State Zip Code PO Box or Street Address City State Zip Code Mailing Address (if different) 7 City Entity Phone Email Address ( ) Check here to receive notices electronically Nevada Secretary of State BL Exemption Other Revised: 10-1-10 American LegalNet, Inc. www.FormsWorkFlow.com