STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES PO Box 1768 Madison, WI 53701-1768 (608)266-2139TTY: Internet www.wdfi.org SECURITIES AGENT SIMULTANEOUS REGISTRATION DISCLOSURE APPLICATION In order for a securities agent to simultaneously represent more than one broker-dealer or issuer who are not affiliated by direct or indirect common control, Section 551.402(5)-(6), Wis. Stats., requires that the Division of Securities grant approval in writing prior to the agent engaging in such activities. That statute and administrative rule SEC 4.01(8), Wis. Adm. Code, thereunder, requires a written application, which may be a copy of the Form U-4 or in letter form, to be filed with the Division in addition to this disclosure form that contains certain required information. Rule 4.01(8) requires that EACH broker-dealer or issuer the agent represents to grant written permission to the agent to represent specified other employers, to list all restrictions they have imposed on the agent222s securities activities, and to provide written disclosure of such information to the applicant222s customers. Also, the rule requires the agent to sign the disclosure form. Each employing broker-dealer or issuer must provide with this application a copy of the form of written disclosure that will be used to advise clients of the agent222s simultaneous registration status. Approval of the application for simultaneous registration, if granted, will be evidenced on this form by the Administrator (or a designee) and a copy supplied to each of the agent222s broker-dealer or issuer employers. Alternatively, the Division may communicate its approval in another written form such as an e-mail message. EACH PARTICIPATING BROKER-DEALER OR ISSUER MUST COMPLETE THE ASIM(WI) FORM WHICH FOLLOWS ON THE NEXT PAGE DFI/DOS/ASIM(R) 1 of 2 This document can be made available in alternate formats upon request to qualifying individuals with disabilities. This form is required under Section 551.402 Wis. Stats.. Failure to comply within 30 days may result in the denial of a registration. Information requested may also be used for secondary purposes. American LegalNet, Inc. www.FormsWorkFlow.com SECURITIES AGENT SIMULTANEOUS REGISTRATION DISCLOSURE APPLICATION A SEPARATE APPLICATION MUST BE COMPLETED BY EACH PARTICIPATING BROKER-DEALER OR ISSUER The undersigned (name of broker-dealer or issuer) acknowledges that (name of applicant) is/seeks to become (cross-out as applicable) registered in Wisconsin as a securities agent to represent the undersigned. The undersigned hereby grants permission for the applicant identified above to be simultaneously registered with the undersigned as well as the following securities broker-dealer(s) or issuer(s): The undersigned hereby grants permission for the applicant identified above to simultaneously represent the other securities broker-dealers or issuers listed in the above paragraph, subject to the following restrictions: The undersigned agrees to provide to each securities customer of the undersigned, written disclosure of the information contained on this form regarding the simultaneous representation by the above identified applicant of more than one broker-dealer or issuer not later than the date of receipt of the confirmation for the first securities transaction for the account of the customer effectuated by the agent after simultaneous registration of the agent is approved by the Division of Securities. Typed/Printed Name Appropriate Signatory Title of Appropriate Signatory Date Signature of Signatory I acknowledge and verify that the employment information listed above is accurate and agree to the restrictions placed upon my securities activities. Date Signature of Agent This form is required under Section 551.402, Wis. Stats. Failure to comply within 30 days may result in fines, penalties or revocation of your registration. DFI/DOS/ASIM(R) 2 of 2 FOR DIVISION OF SECURITIES OFFICE USE ONLY Simultaneous Registration Approved: Date: American LegalNet, Inc. www.FormsWorkFlow.com