State of Wisconsin Department of Financial Institutions Jim Doyle, Governor AGENT LICENS ES FOR ISSUER APPLICAT ION FOR RENEWAL This form is required by section 4.07(1)c, Wis. Adm. Code to renew the licenses of persons offering securities of the issuer to the public. Failure to comply within 30 days may result in fines, penalties or revocation of the license of all agents. SEE SUPPLEMENTAL INFORMATION ON PAGE 4 1. Exact name, principal business address, mailing address (if different) and telephone number of issuer: (a) Full name of issuer: _________________________________________________________________ (b) Name under which business is conducted: _________________________________________________________________ (c) Address of principal place of business: _________________________________________________________________ (d) Mailing address: _________________________________________________________________ (e) Telephone number: _________________________________________________________________ 2. Branch offices of issuer located in Wisconsin: Office Address Name of Person In Charge ______________________________ _____________________________ ______________________________ _____________________________ Division of Securities th Mail: PO Box 1768 Madison, WI 53701-1768 Courier: 345 W. Washington Ave. 4 Floor Madison, WI 53703 Voice: (608) 266-1064 Fax: (608) 264-7979 TTY: (608) 266-8818 Internet: www.wdfi.org >>>> 2S.551.32(7) Wis. Stats. and 4.07(1)c Wis. Adm. Code 3. Description and offering prices of securities being offered and sold in Wisconsin: Complete Description Offering Price _____________________________________ _______________________ _____________________________________ _______________________ _____________________________________ _______________________ _____________________________________ _______________________ 4. There have been no material changes in the information contained in the latest initial application, renewal application or amended application for each agents license except as follows: 5. The name of the issuers officer or general partner who is responsible for the supervision of the offer and sale of the issuers securities and the activities of the issuers licensed securities agents: 6. Neither the issuer nor any of its officers, directors, partners, nor any of its agents licensed in this state, has had a registration or license as a broker-dealer or agent in securities denied, revoked, or suspended by any state, federal public or private regulatory agency, nor has any such person been convicted of the commission of any criminal offense involving fraud, breach of fiduciary obligation, or violation of state or federal securities laws; nor has any such person been the subject of any adverse judgment in any civil proceeding involving any securities transactions or the violation of state or federal securities laws since the date of its last application for license, except as follows: 7. No complaint has been filed against the applicant or any of its officers, directors, partners, or any of its agents licensed in this state in any civil or criminal proceeding, or in any administrative proceeding by any state or federal public or private regulatory agency, concerning its general securities business or financial condition, or any of its securities transactions or customers in this state since the date of its last application for license, except as follows: 8. The name, title, business address, area code, telephone number, and extension number of the individual who may be contacted for additional information, corrections, or clarification with respect to this application: DFI/DOS/AIR (R 7/00) 05/19/03 2 of 4 >>>> 3S.551.32(7) Wis. Stats. and 4.07(1)c Wis. Adm. Code Applicant hereby makes application to the DFI-Division of Securities for renewal of the securities agent licenses of the following individuals, authorizing said individuals to represent the undersigned issuer in the sale of securities in Wisconsin. The application is accompanied by the $30.00 filing fee for each individual named below, and the applicant agrees to pay any expenses reasonably attributable to any investigation or examination of the agent(s) that the Administrator may find necessary with respect to this application. The undersigned issuer takes responsibility for the acts of the agent(s) in the sale of securities in this state. If, prior to the end of the license period, any of the agents named below cease to represent the issuer in the sale of securities or the issuer completes its offering(s) in Wisconsin, the applicant agrees to make application for withdrawal of said agent(s) securities licenses pursuant to Wis. Adm. Code section Sec. 4.08(2): Last Name, First Name, & List Issuers Currently Middle Initial Representing 1. ________________________ ________________________________ 2. ________________________ ________________________________ 3. ________________________ ________________________________ 4. ________________________ ________________________________ 5. ________________________ ________________________________ 6. ________________________ ________________________________ 7. ________________________ ________________________________ 8. ________________________ ________________________________ 9. ________________________ ________________________________ 10. ________________________ ________________________________ DFI/DOS/AIR (R 7/00) 05/19/03 3 of 4 >>>> 4S.551.32(7) Wis. Stats. and 4.07(1)c Wis. Adm. Code Applicant certifies that this application is true, correct, and complete, and agrees that any material changes in any statements made herein or in any exhibits attached hereto shall be reported to the Administrator within 30 days after the occurrence of such changes. Applicant agrees to comply with the provision of the Wisconsin Uniform Securities Law and all rules and orders of the Administrator thereunder. All statements made herein and exh attachibits ed hereto shall be deemed representations made to the Administrator in connection with any determination made or license issued with respect to this application. Dated this ___________ day of _________________, 20 ____. _________________________________________ N ame of Issuer By _________________________________________ Signature and Title SUPPLEMENTAL INFORMATION 1. The expiration date of a securities agent license to represent an issue