NY FORM RI-1 REGISTRANT INFORMATION FORM1.Last Name First Name Middle Name2.Business Address Street City State Zip Code3. 4(a). 4(b). Place of Birth Date of Birth A IPRI-1(NEW YORK STATEDEPARTMENT OF LAWINVESTOR PROTECTION BUREAUNew York, NY 1 TDD (for hearing impaired) 1-800-788-9898www.ag.ny.gov 11.The following is my complete employment and business record including periods of self-employment and unemployment for thepast five years:FromToName and Address of EmployerType ofBusinessPosition Held Mo. Yr. Mo. Yr. 12.The following is a complete record of my business affiliations for the past five years, including all entities not listed in 11 above,under my control or in which I was a principal shareholder (10% or more) or in which I held a substantial equity or controllinginterest (10% or more) or of which I was an officer, director, general partner, trustee or principal.FromToName and Address of EntityType ofBusinessPosition Held Mo. Yr. Mo. Yr. Date: Signature: STATE OF ) : SS.: COUNTY OF ), being duly sworn, deposes and says that I am the person described in and whosigned the above registrant information form. I have read the questions and answers and information supplied, and they are true, accurateand complete. (Signature of Affiant)Sworn to before me this day of , 20.(Notary signature and legible official stamp) President or General Partner American LegalNet, Inc. www.FormsWorkFlow.com IP RI-1 /) Page 2 of 2