§551.32(1) and (8), Wis. Stats., and s. DFI-Sec 4.01(2) and 4.07, Wis. Adm. Code STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES 345 West Washington Ave., 4th Fl. PO Box 1768 Madison, WI 53701-1768 (608) 266-2139 TTY: (608) 266-8818 Internet: www.wdfi.org NON-FINRA MEMBER BROKER-DEALER AND AGENT LICENSE RENEWAL APPLICATION All Wisconsin Broker-Dealer licenses expire on December 31st of each year. This license renewal form must be received by the Division by NOT LATER THAN DECEMBER 1ST. If the renewal form is not received by December 1st, a delinquent filing fee of $100 shall be charged pursuant to s. DFI-Sec 7.01(6) (f), Wis. Adm. Code. A record receipt of your application will be provided if you enclose a self-addressed, postage-paid envelope. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. This form is required under Section 551.32(1) Wis. Stats. Refusal to provide this information may result in the denial of the license renewal. Personally identifiable information on this form may be matched against tax information, outstanding child and family support data and law enforcement agencies. If you have any questions concerning this renewal, please feel free to contact the Licensing & Compliance staff at (608) 266-2139. The undersigned broker-dealer makes application to the Division of Securities for renewal of the license authorizing it to transact securities business in Wisconsin for the calendar year 2008. The application is accompanied by the filing fee of $200.00, $30.00 for each branch office located in Wisconsin and $30.00 for each agent license renewed. The applicant agrees to pay any expense reasonably attributable to any examination of its business or personnel which the Administrator deems necessary with respect to this application. The applicant reaffirms the statements made in its application for initial license as a broker-dealer except as noted on this renewal application, and makes the following statements concerning its securities business and personnel in Wisconsin: Exact name, principal business address, mailing address, if different, and telephone number of applicant: Full Name of applicant (if sole proprietor, last name, first name, and middle initial) Last name First name Middle Initial DFI/DOS/BDR(WI) (R10/07) 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com §551.32(1) and (8), Wis. Stats., and s. DFI-Sec 4.01(2) and 4.07, Wis. Adm. Code Name under which business is conducted Address of principal place of business Street Address City State Zip Mailing address (if different from above) Street Address City State Zip Attach most recently amended Form BD only if it has not been previously submitted to this Division. This would include any regulatory action involving an officer, director, etc. or any complaints. Please list below the name of a person at the firm whom the Division can contact regarding the securities business of the firm and its personnel under the Wisconsin Uniform Securities Law. Name Title The email address that can be used to communicate with the above person: Email address: Branch office(s) of applicant located in Wisconsin: # 1) Branch Manager: Address City Zip Telephone #: # 2) Branch Manager: Number of Agents in branch: Address City Zip Telephone #: Number of Agents in branch: (Attach supplementary sheet if space provided is insufficient.) DFI/DOS/BDR(WI) (R10/07) 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com §551.32(1) and (8), Wis. Stats., and s. DFI-Sec 4.01(2) and 4.07, Wis. Adm. Code The name, title, business address and telephone number of the individual who may be contacted for additional information, corrections, or clarification with respect to this application: Name: Business Address: Address City State Zip Title: Telephone #: Is your firm an FINRA member firm? Yes ___________ No _______________ Applicant makes application to the Division of Securities for renewal of the securities agent licenses of the following individuals, authorizing those individuals to represent the undersigned broker-dealer in the sale of securities for the calendar year 2008. 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 broker-dealer assumes 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 stated above, any of the individuals named below cease to represent the broker-dealer in the sale of securities, the applicant agrees to withdraw the agent's securities license as required by the Rules of the Division of Securities. First Name Middle Init. Last Name Social Security Number (Attach supplementary sheet if space provided is insufficient.) DFI/DOS/BDR(WI) (R10/07) 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com §551.32(1) and (8), Wis. Stats., and s. DFI-Sec 4.01(2) and 4.07, Wis. Adm. Code Applicant certifies that this application is true, correct, and complete, and agrees that any material changes in any statements made in the application or in any exhibits attached to it shall be reported to the Administrator as required by the Rules of the Division of Securities. Applicant agrees to comply with the rules and orders of the Administrator. All statements made in this application and attached exhibits shall be deemed representations made to the Administrator in connection with any decision made or license issued with respect to this application. ________________________________________________ Name of Applicant ________________________________________________ Signature & Title ________________________________________________ Date Copies of this form are available at: http://www.wdfi.org/fi/securities/securapps.htm#Licensing (THIS SPACE RESERVED FOR USE OF THE DIVISION OF SECURITIES) Filing Fees Broker-Dealer Office Agent ______________ ______________ ______________ ============= Receipt Number ________________ ________________ ________________ Date Received ____________ ____________ ____________ TOTAL FEES _______________ DFI/DOS/BDR(WI) (R10/07) 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com