Licensing Section 77 South High Street 22 nd Floor Columbus, Ohio 43215 Com 4751 3/ 20 / 19 An Equal Opportunity Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov File Number: (Office Use Only) FORM SRSIO State Retirement System Investment Officer PART I: State Retirement System 1. Full Name: 2. Address of Principal Place of Business: 3. Telephone No.: 4. Facsimile No.: PART II: Applicant 1. Full Name: 2. Home Address: 3. Telephone No.: 4. Email : 5. Social Security N o.: 6. Fingerprint Card: A fingerprint card properly completed by the applicant: is included with this Form SRSIO will be filed separately PART III: Qualifications 1. Indicate the qualification of the applicant: A. The Division shall consider an applicant for licensing to have met this requirement if the applicant was employed by a state retirement system on, or before, September 14, 2004 and the applicant has satisfied one of the following education and experience requirements or achieved one of the following designations: A relevant investment experience; A doctorate degree from an accredited college or university. American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM SRSIO Com 4751 3/20/19 Earned, and is in good standing with the organization that issued, any one of the following credentials: Chartered financial analyst designation ; Chartered financial consultant; Chartered investment counselor; or Certified public accountant with a personal financial specialist designation. B. For applicants employed by a state retirement system, on or after, September 15, 2004, the applicant must have either: Achieved a passing score on one of the following examinations: The series 63 examination administered by the Financial Industry Regulatory Authority, Inc. The series 65 examination administered by the Financial Industry Regulatory Authority, Inc. Th e series 66 examination administered by the Financial Industry Regulatory Authority, Inc. The level one examination administered by the CFA Institute; or Earned, and is in good standing with the organization that issued, any one of the following creden tials: Chartered financial analyst designation; Chartered financial consultant; Chartered investment counselor; or Certified public accountant with a personal financial specialist designation. PART IV: Disclosure 1. Have you ever been found guilty of any felony? Have you ever been found guilty of any misdemeanor involving theft, deception or moral turpitude? Yes (If yes, attach a sheet reporting the date, place and final disposition of the matter.) No 2. H ave you ever been refused a license or registration, or been censured or disciplined by any State or Federal Agency, Stock Exchange, or FINRA for any activity which would constitute a lack of "good business repute" as defined in O.A.C. 1301:6 - 3 - 19(D)? Yes (If yes, attach a sheet reporting the date, place and final disposition of the matter. ) No American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM SRSIO Com 4751 3/20/19 3. Periods during which the applicant has previously been licensed by the Ohio Division of Securities. (If none, so state.) 4. Employment Record: Complete information must be given covering the ten year period immediately preceding the date of this application. Also include intervals of unemployment. To avoid delays in p rocessing, furnish correct names and address es of all employers. State if former employer is out of business. For additional space attach a separate sheet. Period of Employment Nature of Employment From Name To Address From Name To Address From Name To Address PART V: Signatures 1. Applicant The undersigned represents that the foregoing information is true and accurate to the best of date hereof , and agrees that this form constitutes a written statement for purposes of R.C. 1707.44(B). Date 2. Retirement System The undersigned represents that he/she is duly authorized to do so, the foregoing applicant is employed or has been offered employment, and represents that the information provided in foregoing Parts I, II and III is true and accurate to the best of the retire knowledge as of the date hereof, and agrees that this form constitutes a written statement for purposes of R.C. 1707.44(B). State Retirement System named in Part I : By : Signature (Cannot be the same person as Applicant named in Part II) Print name and title Date American LegalNet, Inc. www.FormsWorkFlow.com