APPLICATION FOR REGISTRATION AS DEALER NORTH DAKOTA SECURITIES DEPARTMENT SFN 51526 (10-2013) Form S-4 Securities Department 600 East Boulevard Bismarck, ND 58505 (701) 328-2910 www.nd.gov/securities Pursuant to the provisions of Section 10-04-10 of the North Dakota Securities Act of 1951, as amended, application is made for registration as a dealer: Note: The registration fee for each dealer is $200 1. Name of Applicant Telephone Number Address City State ZIP Code 2. Form of Business Organization Date of Organization State of Incorporation 3. Attach as Exhibit A the names and business addresses of all members, partners, officers, directors, trustees, managers, or supervisory persons of the applicant. a. List any securities qualifications examination that may have been taken by any of the persons listed in Exhibit A to include the name of the examination, date taken, and grade attained. b. A statement setting forth in chronological order the occupational activities of each such partner, member, officer, director, trustee, or manager for the past ten years. c. In the case of a new dealer, include the investment experience of those listed in (a). 4. Addresses of all branch offices and name of person in charge of each in this state: American LegalNet, Inc. www.FormsWorkFlow.com SFN 51526 (10-2013) Page 2 of 4 5. Describe briefly the general character of the business conducted or proposed to be conducted by the applicant. If application is being made as an issuer-dealer, make a positive statement to the effect that the registration is sought for the limited purpose of selling the issuer's own securities, stating the type and amount proposed to be offered and sold, and that the issuer-dealer is not, and will not conduct a general securities business . 6. If this application is being made to register the applicant as an issuer-dealer, two of the officers of such issuer-dealer may be exempt from the examination requirements. Please list the two officers and their titles for whom this exemption is being applied. They must be officers and must register as an agent. Name: Position: 7. Attach as Exhibit B a list containing the name of each state in which the applicant is, or has been licensed or registered, or has filed an application indicating type registration or license, date of effectiveness or anticipated effective date. If any registration or license has been terminated, refused, canceled, suspended, or withdrawn in any state, give full details, including the date and reason for the termination. (If none, so state.) 8. Attach as Exhibit C the names of all organizations of dealers or brokers of which the applicant is a member or before which any application for membership on the part of the applicant is pending, and whether any such membership of the applicant has ever been denied, revoked, suspended, or has been the subject of proceedings for revocation or suspension. (If none, so state.) 9. List the names of any securities exchange of which the applicant or any of its partners, officers, directors, trustees, members, managers, or employees is a member and whether any such membership has ever been denied, revoked, suspended, or is the subject of proceedings for revocation or suspension. (If none, so state.) 10. Is applicant registered as a dealer under the Securities Exchange Act of 1934 or any Act adopted in amendment thereof? Has any such registration of the applicant ever been denied, revoked, suspended, or is such registration now the subject of proceedings for revocation or suspension by the Securities and Exchange Commission? YES NO Date Date YES NO American LegalNet, Inc. www.FormsWorkFlow.com SFN 51526 (10-2013) Page 3 of 4 11. State whether the applicant, or registrant, or any other person directly or indirectly controlling or controlled by the applicant or registrant, including any officer, director, or partner: a. Has been found by any state or federal regulatory authority or by any court to have violated any statute in any state or federal securities act, or any rule or order or regulation promulgated under or issued pursuant to such act, or to have aided, abetted, counseled, commanded, induced, or procured any such violation by another person. If the answer is "yes" provide the following information: Name Type of Action Name of Court or Agency Position Name of Court or Agency Date of Action YES NO b. Has ever been subject to an order of any state authority barring or suspending the right of such person to be engaged in any trade or business. If the answer is "yes" provide the following information: Name Type of Action Name of Court or Agency Position Name of Court or Agency YES NO Date of Action c. Has been, within the last 10 years, charged, arrested, or convicted of any felony or misdemeanor, except minor highway traffic offenses. If the answer is "yes" provide the following information: Name Type of Action Name of Court or Agency Position Name of Court or Agency YES NO Date of Action d. Has filed for bankruptcy or been determined bankrupt by a court of competent jurisdiction. If the answer is "yes" provide the following information: Name Type of Action Name of Court or Agency Position Name of Court or Agency YES NO Date of Action 12. Additional exhibits as required under the North Dakota Securities Act of 1951, as amended, are listed below and included with this application: a. Consent to Service of Process (Form U-2) b. Corporate Resolution (Form U-2 ABD) c. A financial statement or balance sheet prepared in accordance with standard accounting practice showing the financial condition of the applicant as of the most recent practicable date prior to the date of application, such financial statement or balance sheet to be certified by an independent certified public accountant. d. Articles of Incorporation and By-Laws, Partnership Agreement, or Member Control Agreement. 13. While this application is pending or any license issued under this application is effective, the applicant or registrant agrees to file promptly, but no later than 30 days following the specified event or occurrence, an amended application showing any material change including, but not limited to, the following: changes in ownership, branch managers, officers, directors, partners, actions by any governmental agency or authority directed toward application to its registered salesmen, financial condition, etc. American LegalNet, Inc. www.FormsWorkFlow.com SFN 51526 (10-2013) Page 4 of 4 14. Applic