Oregon Department of Consumer and Business Services Division of Finance and Corporate Securities 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 503-378-4140 Fax: 503-947-7862 http://dfcs.oregon.gov REPRESENTATIVE/SALESPERSON RENEWAL The employer and the representative must complete this form, which should be received by the Division of Finance and Corporate Securities no less than 30 days before the expiration date of the current license in order to ensure adequate processing time. · · · · Incomplete renewal forms will not be processed. The employer must complete and sign the Representative information and the Employer election and verification section. The representative must complete and sign the Disciplinary Reporting Disclosure Questionnaire: Pages 2 and 3. Send the completed form, Pages 1-3, together with a check for the applicable fee payable to the Department of Consumer and Business Services, to the address below. Representative information Employer: Representative's name: Representative's title: Representative's phone number: Representative's home address: City: State: ZIP: Employer election and verification The undersigned has investigated the background of the applicant, has found the applicant to be of good character, and believes the applicant has sufficient knowledge of the employer's business affairs to sell its securities. The undersigned has read this application and all attached materials. To the best of employer's knowledge and belief, this information is true, correct, and complete. Name (print): Signature: Date: Phone no.: Title: SSN: CRD number: Date of birth: - Secure fax for credit card payments: 503-947-2333 If paying by credit card, applicant must sign credit card information box. Visa MasterCard Discover Phone: Expiration date Make check or money order payable to Department of Consumer and Business Services. Do not send cash. DCBS -- Fiscal Services P.O. Box 14610 Salem, OR 97309-0445 PCA code: 62110 Fiscal use only: Credit card number Obj. code: 1001 Name of cardholder as shown on credit card $ Cardholder signature Amount Page 1 of 3 440-2118a (1/13/COM) American LegalNet, Inc. www.FormsWorkFlow.com DISCIPLINARY REPORTING DISCLOSURE QUESTIONNAIRE Review these questions carefully and report any disclosures that have not been previously reported. Yes No 1. Are you currently employed by two or more of the following Oregon-licensed entities: broker-dealer, investment adviser, securities issuer? If yes, list entities here: Has an undertaking (Form 440-2131) been executed? 2. Have you been the subject of any order or administrative action by the director of the Oregon Department of Consumer and Business Services? 3. Have you been given qualified authority or been denied authority to sell securities in any state or country? 4. Have you been the subject of any revocation, cancellation, withdrawal, suspension, or other adverse order or directive of any self-regulatory organization or any state or foreign financial regulatory authority regulating the sales of securities? 5. Have you been the subject of any investigation by any federal regulatory agency or any self-regulatory authority or any state regulating the sales of securities? 6. Have you been the subject of a U.S. Postal Service fraud order or action? 7. Have you been permanently or temporarily enjoined or restrained by any court from engaging in or continuing any conduct or practice involving any aspect of the securities business? 8. Have you been charged with fraud in any civil action? 9. Have you been convicted of, or indicted for, the commission of any felony or misdemeanor? 10. Have you been suspended or barred from the practice of any trade or profession? 11. Have you been the subject of any insolvency or bankruptcy proceeding? 12. Is your current financial condition such that you cannot meet your obligations as they mature? 13. Has any organization owned or controlled by you, or in which you were or are an officer, director, or partner, been the subject of any insolvency or bankruptcy proceeding or become defunct or inoperative during the period of your association with such organization? 14. Are there any unsatisfied judgments or suits against you for collection of obligations? 15. Have you been the subject of an investment-related consumer-initiated complaint? 16. Has any federal regulatory authority, any self-regulatory organization, or any state or foreign financial regulatory authority ever: a) Found you to have made a false statement or omission or been involved in a violation of its rules? b) Found you to have been the cause of an investment-related business having its authorization to do business denied, suspended, revoked, restricted, or disciplined you by expelling or suspending you from membership, barring or suspending your association with its members, or restricting your activities? c) Found you to have willfully violated any provisions of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board, or found you to have been unable to comply with any provision of such act, rule, or regulation? 440-2118a (1/13/COM) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Yes No d) Found you to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board? e) Found you to have failed reasonably to supervise another person subject to your supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act or any rule or regulation under any such acts, or any of the rules of the Municipal Securities Rulemaking Board? 17. Are you now the subject of any complaint, investigation, or proceeding that could result in a "yes" answer to questions 2-16? For each "Yes" answer on questions 2-17, attach a Disclosure Reporting