NEW JERSEY BUREAU OF SECURITIES 153 Halsey Street, 6th Floor, Newark, NJ 07102 Post Office Box 47029, Newark, NJ 07101 (973) 504-3600 AGENT OF THE ISSUER EXAMINATION WAIVER REQUEST The New Jersey Bureau of Securities requires a prospective agent of the issuer to pass the Series 7 (General Securities Representative) examination. This form should be used to request a waiver of this examination requirement and should be filed with the New Jersey Bureau of Securities at the address above. For additional information regarding issuer agent registrations, examinations, and waivers, please call (973) 504-3661. Name of Issuer (company): _____________________________________________________ Street Address: _______________________________________________________________ City: _______________________________ State: _____________ ZIP Code: ____________ Name of Issuer Agent (individual): _______________________________________________ Office Telephone Number: _____________________________________________________ Type of Securities (common stock, warrants, bonds, etc.): ____________________________ The undersigned hereby certify as follows: 1. The issuer agent and the issuer’s executive officers would not be disqualified from conducting offers and sales of the issuer’s securities by Regulation A under the Securities Act of 1933. 2. The issuer agent has the following securities-related experience: a. Nature of duties: _________________________________________________________ b. Name of employer(s): _____________________________________________________ Signature of Officer of the Issuer: Signature of Applicant: _________________________________ _________________________________ Title: ____________________________ Date: ____________________________ Date: ____________________________ Form NJBOS-15, 7/2004 American LegalNet, Inc. www.USCourtForms.com