STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS BROKER DEALER QUESTIONNAIRE AND AFFIDAVIT: PRIOR SALES Date: Full Name of Broker Dealer: Firm CRD No: EIN No: The undersigned certifies as follows: I have made reasonable inquiries into the activities of_________________________________ and, to the best of my knowledge, information and belief, within the past twentyBroker Dealer four (24) months, ______________________________ has not made any offers or sales of securities, other than offers or Broker Dealer sales for which the broker dealer is exempt under the Rhode Island Uniform Securities Act of 1990 (“RIUSA”). If you cannot certify to the above for any offers or sale, provide the following information concerning those offers or sales: x A list of customers to whom securities were offered or sold in the past 24 months, including account holder’s name and telephone number. x A list of transactions executed within the twenty-four month period, including x Name of the security x Date and amount of the trade x The agents who effected the trade x Total commission paid on each trade to the broker dealer and the agent The Securities Division may verify this information with your clearing firm. AFFIDAVIT I ______________________________, a principal registered with _______________________________, have conducted a review of Name of Principal Broker Dealer Name _________________________________’s records. The result of this review shows that the information provided above is true and Broker Dealer Name correct to the best of my knowledge, information and belief, and accurately reflects the activities within Rhode Island. I further certify that ____________________________, will refrain from transacting business as a broker dealer in Rhode Island until registration is Broker Dealer Name complete. 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 sanction pursuant to RIUSA. _________________________________________________ Signature of Principal Subscribed and sworn before me this____________ day of ________________________ 20______ County of __________________________ State of______________________________ My commission expires______________________ __________________________________________________ Notary Public DESIGNATED SUPERVISOR At least one (1) person of the broker dealer with a valid Series 24, shall be designated in the license application to act in a supervisory capacity, and be licensed as a registered representative of the broker dealer with this state. __________________________________ Series 24 Individual CRD No. _________________________ American LegalNet, Inc. www.FormsWorkflow.com