Oregon Department of Consumer & Business Services Division of Finance & Corporate Securities Securities Section 350 Winter St. NE, Room 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 (503) 378-4140 Fax: (503) 947-7862 TTY: (503) 378-4100 www.oregondfcs.org INVESTMENT ADVISER RENEWAL APPLICATION Name of licensee:_______________________________________License number:IA________________ ( ) Contact person:_________________________________________Phone: ________________________ Title of contact person:___________________________________Fax: __________________________ The investment adviser firm identified above hereby applies for renewal of its license in Oregon and submits thisapplication and a renewal fee of $200 to the Division of Finance and Cor porate Securities. All material changes for the past year, as defined in OAR 441-175-0105, have been filed with the Division of Finance and Corporate Securities or are shown on the amended Form ADV fi led with this renewal application. Name of the firms supervisor of operations in Oregon:__________________________________________ VERIFICATION I declare, under penalty of perjury, that I am________________________(Title or position) of the licensee and I am fully authorized to file this renewal for and on behalf of the licensee. I have read and am familiar with the information in this renewal and with all materials or documents accompanying it. To the best of my knowledge and belief, the information contained in this renewal and the accompanying documents is true, correct, and complete. By (Type or print name): ______________________________________Date:__________________ Signature:__________________________________________________ FISCAL USE ONLY: 62110/1001 $200.00 DD DEPARTMENT OF CCONSUMER B BUSINESS S SERVICES 440-2306 (3/04/COM) American LegalNet, Inc. www.USCourtForms.com