West Virginia State Auditor’s Office Glen B. Gainer III, State Auditor Form 16: Application for Renewal of Dealer's Registration Name of Dealer ________________________________________________________________ BD#________________________ Address ____________________________________________________________________________________________________ City _________________________________________________________________State ________ Zip ______________________ Telephone _________________________________ Name of person to contact for further information ____________________________________________________ Telephone _________________________________ Address, if different from dealer ______________________________________________________________________________________________________ Briefly describe type of securities to be sold ____________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ All securities offered for sale in West Virginia during the past fiscal year have qualified for sale or exempted under the provisions of Article 3, Section 32-3-301, of the Code, of West Virginia, as amended 1974, Regulating and Supervising the Sale of Securities. Exceptions, if any, list as EXHIBIT #1. All material changes affecting this dealership, since last resignation, have either been furnished, or are included herewith, such as amendments to the Charter, By-Laws, Agreement, etc., or attached as EXHIBIT #2. A Schedule "A" of Form BD listing the current officers of this dealership is attached as EXHIBIT #3 Form U-4, covering _______ salespersons, if any, for which license renewal is requested and a check for the renewal fee of $65.00 each is enclosed. An Audited Income Statement and Balance Sheet is enclosed unless previously filed since last registration or renewal date. If filed, give date. If not, attach as EXHIBIT #4 The date our fiscal year ends is _________________________________. No officer, employee or salesperson has been charged with a felony or violation of any securities law or rule or regulation of any securities exchange or the NASD Inc., within the past year except: (Explain the violation and disposition.) __________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ If more space needed, file EXHIBIT #5 As a condition for renewal of this dealership "I/We do hereby agree to permit the examination of our books, records, and any other information requested, during normal business hours, by the Commissioner of Securities of West Virginia, and/or his appointed agent(s), as authorized under Section 32-2-203(d) of the Code of West Virginia, 1931, as amended 1974. The undersigned does " solemnly swear that the foregoing statements, attachments and/or exhibits and forms, are true, accurate and complete to the best of my knowledge, and agrees to abide by the West Virginia Securities Laws, Rules and Regulations. (Corporate Seal) Print Name: _______________________________________ Signed: ________________________________________________________ Title: ____________________________________________________________ Subscribed and sworn to before me, a Notary Public, in and for the County of_____________________________________ State of _________________, this the _____________ day of _____________________. (Notary Seal) ____________________________________________________ Notary Public My Commission Expires: ____________________ American LegalNet, Inc. www.USCourtForms.com