REGISTERED SECURITIES AGENT APPLICANT CERTIFICATION I, _______________________________________, CRD number ____________, hereby certify to the Administrator of the Oklahoma Department of Securities that I have carefully reviewed the Oklahoma Uniform Securities Act of 2004, 71 O.S., §§ 1-101 through 1-701, as well as the rules and regulations adopted thereunder, and I fully understand my responsibilities thereunder as a registered securities agent. I so certify and make this filing with the Administrator in connection with my application as a securities agent: Dated this _____day of _____________. 20___. ______________________________________________ (Signature) STATE OF.......................................................... ) ) SS COUNTY OF......................................................) Subscribed and sworn before me this _____ day of ____________, 20 ____, _______________________________________ My Commission Expires:____________________ MANAGEMENT CERTIFICATION I, _________________________________________, an officer, director, partner or sole proprietor of _____________________________________________________________________, hereby certify to the Administrator of the Oklahoma Department of Securities that the above applicant for registration as a registered securities agent has been provided adequate instruction with respect to his/her responsibilities under the Oklahoma Uniform Securities Act of 2004, and the rules and regulations adopted and promulgated pursuant thereto. Dated this _____day of _____________. 20___. ______________________________________________ (Signature) ______________________________________________ (Title) STATE OF.......................................................... ) ) SS COUNTY OF......................................................) Notary Public Subscribed and sworn before me this _____ day of ____________, 20 ____, _______________________________________ My Commission Expires:____________________ Notary Public D-18 7/2004 American LegalNet, Inc. www.FormsWorkFlow.com