BROKER-DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES Firm CRD No.: Date: Full Name of Broker-Dealer: SEC File No.: 8- The undersigned certifies as follows: I have conducted a thorough review into the activities of the Brokerdealer listed above and, to the best of my knowledge within the past 36 months, the firm has not effected non-exempt transactions in the state(s) indicated below. Alabama Alaska Arizona Arkansas California Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ALL If any transaction were made in reliance upon an exemption, I have attached a list of those transactions. As to those transactions, I have identified the exemption upon which the broker-dealer relied and an explanation. For those transaction that occurred within the past 36 months which were effected without the benefit of an exemption. I am providing the following information: • The accountholder's name, address and telephone number. • Name of the security. • Date and amount of the trade, including the commission paid to the Brokerdealer and to the Agent. • The Agent who effected the transaction. I am aware that the state may verify this information with my clearing firm. I further certify that the Broker-dealer listed above will refrain from transacting business as a BrokerDealer in the jurisdictions shown until registration is completed. I acknowledge that if my response to any of the above is false or if the Broker-Dealer transacts business during the period prior to registration, the Broker-Dealer and I are subject to sanctions pursuant to the laws of the particular jurisdiction involved. Name of Principal (please print) Signature of Principal Subscribed and sworn before me this County of day of , , State of . . My commission expires . Notary Public American LegalNet, Inc. www.USCourtForms.com