Oregon Department of Consumer & Business Services Division of Finance & 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 ! TTY: (503) 378-4100 www.oregondfcs.org REPRESENTATIVE RENEWAL OR TERMINATION To RENEW the license of a representative shown as active on the attached computer print-out, the employer and employee must complete this form, which must be received by the Securities Section no less than 30 days before the expiration date of the current license. Incomplete renewal forms will not be processed. The employer must compl ete the employee information section and sign the election and verification. The employee must complete and sign the disciplinary reporting disclosure questionnaire. Send the completed form , with a check for $50 payable to Department of Consumer & Business Services, to the address above. To TERMINATE a license, the employer must complete the employee information section, complete and sign the termination section, and return the form to the address above. Employee information Employer: Representatives name: SSN: - - Representatives birth date: CRD number: Representatives phone number: Representatives home address: City: State: ZIP: Employer election and verification Employer has investigated the background of this person and believes thi s person to be of good repute and to have the knowledge, experience, and ability to sell on behalf of the employer. Em ployer has read this application and all attached materials. To the best of employers knowledge and belief, this infor mation is true, correct, and complete. Phone number: Date: Name (type or print): Title (type or print): Signature: Termination To terminate this license, check here , sign, and submit. Phone number: Date: Name (type or print): Title (type or print): Signature: Visa MasterCard Make check or money order payable to Oregon Division of Finance and Corporate Securities. If paying by credit card, applicant must sign credit-card-information box. Credit card number Expiration date DCBS Fiscal Services Name of cardholder as shown on credit card P.O. Box 14610 $ Salem, OR 97309-0445 Cardholder signature Amount Fiscal use only: 62110/1001 Fee: $50 Page 1 of 2 440-2118 (1/04/COM/WEB) American LegalNet, Inc. www.USCourtForms.com>>>> 2 DISCIPLINARY REPORTING DISCLOSURE QUESTIONNAIRE Have any of the following occurred or materially changed in the last 12 months? Yes No 1. Are you currently employed by two or more of the following Oregon-licens ed 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 d irector 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, s uspension, or other adverse order or directive of the National Association of Securities Dealers; an y securities exchange; or any state, province, or federal agency regulating the sale of securities? 5. Have you, to the best of your knowledge, been the subject of any investigation by t he National Association of Securities Dealers; any securities exchange; or any state , province, or federal agency regulating the sale 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 c ourt from engaging in or continuing any conduct or practice involving any aspect of the securitie s business? 8. Have you, to the best of your knowledge, been charged with fraud in any civil action? 9. Have you been convicted of or indicted for the commission of any crime o r crimes other than traffic violations? 10. Have you been suspended or barred from the practice of any trade or prof ession? 11. Have you been the subject of any insolvency or bankruptcy proceeding? 12. Is your current financial condition such that you cannot meet your oblig ations 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 co mplaint? 16. Are you now the subject of any complaint, investigation, or proceeding t hat could result in a yes answer to questions 2-15? If you answer Yes to any of questions 2-16, attach a Disclosure Reporting Page (from Form U-4) for each. Representative verification I hereby attest that, to the best of my knowledge, information, and beli ef, the information contained in this application and in the attached materials is true, correct, and complete. Date: Signature: Reminder: Amendments to Form U-4 must be submitted within 30 days of any material change (OAR 441-175-0105). Page 2 of 2 440-2118 (1/04/COM/WEB) American LegalNet, Inc. www.USCourtForms.com