FORM R-2 11-06 Commonwealth of Puerto Rico COMMISSIONER OF FINANCIAL INSTITUTIONS Centro Europa Building, Suite 600 1492 Ponce de León Avenue San Juan, PR 00907-4127 Tel. (787) 723-8403 Fax (787) 724-2604 APPLICATION FOR REGISTRATION, RENEWAL OR AMENDMENT TO AN APPLICATION OF AN AGENT ____________________________________________________________________________________________ Check the appropriate box: Application for Initial Registration Application for renewal of registration Amendment to an application ( ( ( ) ) ) ____________________________________________________________________________________________ 1. 2. Name of Applicant Social Sec. No. CRD No. Home Address of Applicant _______________________________________________________________ _____________________________________________________________________________________ 3. Name and Address of issuer whom Applicant will represent . _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Address and telephone number of Applicant’s regular place of business in Puerto Rico ______________ _____________________________________________________________________________________ _____________________________________________________________________________________ Citizenship ________________________ 5. Date and place of birth 6. How long has Applicant lived in Puerto Rico________________________________________________ 7. Summarize Applicant’s educational background, including schools attended, dates of attendance and degrees received. ______________________________________________________________________________________ 8. Summarize Applicant’s occupation for the last 10 years, including names and addresses of employers, dates of employment and a general description of the duties of each employment. _____________________________________________________________________________________ ______________________________________________________________________________________ 9. Has Applicant engaged in the securities business on a full time basis for the 5 years immediately preceding the date of filing of this application? _____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 10. Describe Applicant’s proposed method of doing business, including (1) whether Applicant will specialize in any type of business or securities, (2) whether Applicant will devote his full time to the securities business, and if not, the approximate percentage of Applicant’s time which will be devoted to the securities business, (3) whether Applicant will solicit employment as an issuer’s agent from issuers of securities. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 11. State whether Applicant: Yes No (a) Has ever been convicted of any misdemeanor involving a security or any aspect of the securities business? (b) Has ever been convicted of any felony? (c) Has ever been permanently or temporarily enjoined from engaging in, or continuing any conduct practice involving any aspect of the securities business? d) Has ever been the subject of an order of the Administrator denying, suspending or revoking registration as a broker-dealer, agent or investment adviser? (e) Has ever been the subject of an order entered by the Securities Administrator of any other state or by the Securities and Exchange Commission denying or revoking registration as a broker-dealer, agent or investment adviser? (f) Has ever been the subject of an order of the Securities and Exchange Commission suspending or expelling him from a national securities exchange or national securities association registered under the Securities Exchange Act of 1934? (g) Has ever been adjudicated as bankrupt or insolvent? (h) Has ever been censured or fined, suspended or expelled by the National Association of Securities Dealers, Inc. or by any stock exchange? (I) Has ever been the subject of a United States Post Office Fraud Order? Has ever been sued civilly for fraud, deceit or misrepresentation? (j) If the answer to any of the foregoing question is in the affirmative furnish the complete details including concerning the current status of the case. the date and a statement If during the period of your registration an event occurs which would cause a current affirmative answer to any part of item 11, the Assistant Securities Commissioner shall be notified in writing as to the facts relative to such event. 12. Has Applicant ever been known by another name? name changed. 13. If so, what name and when and by whom was The following exhibits are to be filed herewith. I. A bond in the amount of $2,000.00 as required by Section 6.7.2 (b) of the Regulation under the Uniform Securities Act of Puerto Rico. American LegalNet, Inc. www.FormsWorkflow.com CONSENT TO SERVICE OF PROCESS The Applicant irrevocably appoints the Commissioner of Financial Institution of Puerto Rico, and his successors in Office, its attorney upon whom may be served any notice, process or pleading in any non-criminal action or proceeding against it arising out of or in connection with the purchase or sale of securities, the conduct of the securities business or the business of an investment adviser, or violation of the Uniform Securities Act of Puerto Rico; and the undersigned does hereby consent that any such action proceeding against it may be commenced in any court of competent jurisdiction and proper venue by service of process upon said officer with the same effect as if the undersigned has been personally served with process in said jurisdiction. It is requested that a copy of any notice, process or pleading served hereunder be mailed to the address given in Item 3 and 4. EXECUTION I, the undersigned Applicant, being duly sworn on oath, state that I have read and knowingly made the foregoing statements and representations and that each and all such statements and representations are true, and ask that the license herein applied for be granted. If the foregoing is an amendment to a current registration the undersigned represents that the statements made in the amendment and in the current registration to the extent not corrected by the amendment, are true, correct, and complete. __________________________________ Signature of Applicant ___________________________ Date of signing Affidavit Number: ___________________________ of legal age, Subscribed and sworn to before me by personally known to me this and resident of day of of 20 , , at . ___________________________ Notary Public A filing fee of $150.00 as required by Section 6.7.2 (b) of the Regulation under the Uniform Securities Act of Puerto Rico must accompany this application in the form of check or money order drawn to the “Secretary of the Treasury” American LegalNet, Inc. www.FormsWorkflow.com