Dealer Renewal Application (Issuer-Dealer) {S-6}

ISSUER DEALER RENEWAL APPLICATION NORTH DAKOTA SECURITIES DEPARTMENT SFN 51532 (10-2013) FORM S - 6 Securities Department 600 E Boulevard Ave Dept 414 Bismarck ND 58505 (701) 328-2910 www.nd.gov/securities NOTE: Registration of Dealers and Agents may be renewed each year at any time not less than 15 and not more than 30 days before December 31. This form is to be completed for dealer renewal or termination purposes. (OR) RENEWAL TERMINATE Telephone Number NOTE: If a firm is terminated, the agent(s), if any, will also be terminated. 1. Name of Firm Registered as Issuer/Dealer Address City Contact Person 2. State the name of each registered agent to be renewed (attach a separate sheet if needed). A termination notice in letter form must be filed for each agent whose registration will not be renewed and, if applicable, an application (Form S-5) must be completed for each new applicant. The Form S-5 is available at http://www.nd.gov/eforms/Doc/sfn51529.pdf State ZIP Code 3. It is hereby certified that since the last dealer renewal date, the North Dakota Securities Department has been notified by this dealer in writing of all material changes, if any, of a substantial nature that have taken place affecting the dealer, its officers, directors, partners, managers, agents, and employees. This would include any disciplinary action or other proceedings that have been taken by any federal or state agency or by any national securities exchange or national securities association. Yes No If "No", indicate exhibit here 4. It is further certified that in all cases where agents have left our employ for whatever reason, that a termination notice has been filed with the North Dakota Securities Department. Yes No 5. Describe the principal types of business engaged in by the applicant and types of securities being sold. 6. Enclose payment of proper fee for renewal of dealer and agents as provided in the North Dakota Securities Act: For each dealer in this state: $200.00 AND For each applicant to be renewed and/or new registration filing: $60. Dated this day of , year . Print Name of Person Signing for Dealer (Corporate Seal) Signature of Person Signing for the Registered Dealer Title American LegalNet, Inc. www.FormsWorkFlow.com