Rev / New York State Office of the Attorney General InvestProtection Bureau , 2 Floor New York, NY 1 Investment Adviser Qualification (NY-IAQ)1.(A) Name of Individual(B) Individual CRD number2.(A) Name of Investment Adviser Entity(B) Investment Adviser Firm CRD number(C) Investment Adviser Firm Address3.Have you taken and received a passing grade within the past two (2) years on the:(A) Uniform Investment Adviser Law Examination (Series 65 examination) Yes No (B) General Securities Representative Examination (Series 7 examination) and the Uniform Combined State LawExamination (Series 66 examination) Yes No ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Request for Waiver of Examination 4.Have you taken and passed Uniform Combined State Law Examination (Series 66) in the past two (2) years and the GeneralSecurities Representative Examination (Series 7) more than two years ago? Yes No5.Are you an individual who represents an investment adviser in doing any of the acts which makes that person an investmentadviser as defined in subsection 11.12(f), or solicits business for an investment adviser, and who has been continuouslyregistered in any jurisdiction, other than New York, for a period of two (2) years prior to the date of filing registration informationpursuant to section 11.4(c)? (The individual may have no lapse in employment as an investment adviser representativeexceeding 2 years) 037 Yes 037 No6.Have you had any regulatory actions or arbitrations in the last five (5) years? Yes No If the answer is yes, attach statement of full particulars.7.Do you hold one of the following designations? (Check all that apply and provide documentation) Certified Financial Planner(CFP) awarded by the Certified Financial Planner Board of Standards, Inc. Chartered Financial Consultant (ChFC) awarded by the American College, Bryn Mawr, Pennsylvania. Personal Financial Specialist (PFS) awarded by the American Institute of Certified Public Accountants. Chartered Financial Analyst (CFA) awarded by the Association for Investment Management Research. Chartered Investment Counselor (CIC) awarded by the Investment Counsel Association of America, Inc. Other designation to be considered (attach an explanatory letter and documentation).------------------------------------------------------------------------------------------------------------------------------------------------ All statements contained herein are true and correct and undersigned understands that any false statement shall constitute a violation of Article 23-A of the General Business Law. Dated: By: Signature of Individual Sworn to before me this day of201 Notary Public American LegalNet, Inc. www.FormsWorkFlow.com