Application For Registration Of Agent (Issuer-Dealer) {S-5}

APPLICATION FOR REGISTRATION OF AGENT NORTH DAKOTA SECURITIES DEPARTMENT SFN 51529 (10-2013) INSTRUCTIONS FORM S-5 Securities Department 600 E Boulevard Ave Bismarck ND 58505 (701) 328-2910 www.nd.gov/securities The answers provided in this application are submitted UNDER OATH. Any applicant who willfully and contrary to such oath shall state or subscribe any material fact which he does not believe to be true is guilty of perjury and is punishable by imprisonment in the penitentiary. In addition, registration may be refused, suspended, or revoked if the applicant has filed an application which is incomplete in any material respect or contains any statement which was, in the light of the circumstances under which was made, false or misleading with respect to any material fact. All questions in this application must be answered legibly, responsively, and fully, and failure to do so may result in rejection of the application. If additional space is required in which to answer a question, attach a separate sheet and specify the number of the question in response to which the answer is given. TO THE SECURITIES COMMISSIONER OF THE STATE OF NORTH DAKOTA: Pursuant to the provisions of Section 10-04-10 of the North Dakota Century Code, as amended, the undersigned hereby applies for registration as a securities agent and submits the following SWORN answers to the questions contained herein: 1. Name (Last, First, Middle): 2. Indicate any other name or names (including maiden name) by which you have been known or which you have used. If "none," so state. 3. Business Address: 4. Residence Address: City: City: State: State: ZIP Code: ZIP Code: 5. Name of dealer employing or proposing to employ applicant. If applicant proposes to be self employed, so state. If applicant proposes to be employed complete Item 6 6. If applicant proposes to be self-employed, please indicate so below and state the particular security or securities you propose to sell in this state, including the name of the issuer. SELF-EMPLOYED: Securities and Issuer: Yes No 7. Complete the following employment record for the ten-year period immediately preceding the date of application. BEGINNING WITH THE PRESENT and continuing in chronological order. Where self-employment is applicable, furnish the name under which business was conducted, location, and nature of business. Periods of unemployment must be shown. Indicate reason for resignation or discharge. From Month Year Month To Year Employer Address Position Reason for Leaving American LegalNet, Inc. www.FormsWorkFlow.com SFN 51529 (10-2013) Page 2 of 4 8. Are you registered as a representative with the Financial Industry Regulatory Authority (FINRA)? 9. Are you registered as a representative with a national stock exchange? which exchange are you registered and for how long have you been so registered? Yes No Yes If "yes," with No 10. Have you ever offered for sale or sold securities in the State of North Dakota prior to the date of this application? Yes No If "yes," explain fully. 11. List each state (including North Dakota) and province in which you are or have been registered as a dealer or agent to sell securities, specifying the date(s) of such registration(s). 12. Have you ever been denied or been given qualified authority to sell securities in any state or province? Yes No 13. Are you now or have you ever been subject to any revocation, cancellation, withdrawal, suspension, or any adverse order or directive of the FINRA, any Canadian self-regulatory association, any securities exchange, or any state, provincial, or federal agency which has the power to revoke, suspend, or deny membership or registration? Yes No 14. Have you ever been permanently or temporarily enjoined by any court from engaging in or continuing any conduct or practice involving any aspect of the securities business? Yes No 15. Has any broker or dealer with whom you were associated in any capacity when such action was taken ever had its membership or registration denied, canceled, suspended, or revoked or been the subject of any injunctive proceeding involving securities? Yes No 16. Have you ever been a direct or beneficial owner of 10% or more of the stock of or interest in or an officer of a securities dealer whose registration was denied, canceled, suspended, or revoked during such period of interest or employment? Yes No 17. Have you ever been a subject of any arrests, information, presentments, indictments, or convictions for any felony or misdemeanor, except minor traffic offenses? Yes 18. Have you ever been charged with fraud in civil action? 19. Have you ever been barred or suspended from the practice of any business or profession? Yes Yes No No No American LegalNet, Inc. www.FormsWorkFlow.com SFN 51529 (10-2013) Page 3 of 4 20. (a) Have you ever been refused a surety or fidelity bond? (b) Has any surety company paid out any funds on your coverage? 21. Have you or any organization owned or controlled by you or in which you were or are an officer, director, or partner ever been the subject of an insolvency or bankruptcy proceeding? Yes Yes Yes No No No IF YOUR ANSWER TO ANY ONE OF QUESTIONS 12-20 ABOVE IS "YES," FURNISH THE FOLLOWING INFORMATION ON A SEPARATE SHEET OF PAPER INCORPORATED AS A PART OF THIS APPLICATION: NAME OF FEDERAL, STATE, OR PROVINCIAL AGENCY, SECURITIES EXCHANGE, OR SECURITIES ASSOCIATION; NAME AND LOCATION OF BROKER OR DEALER WITH WHOM YOU WERE ASSOCIATED AND CAPACITY IN WHICH YOU WERE ASSOCIATED; DESIGNATION OF STATUTES, RULES, OR REGULATIONS WHICH YOU OR THE BROKER OR DEALER WITH WHOM YOU WERE ASSOCIATED WERE CHARGED WITH VIOLATING AND CHARGES MADE; NATURE AND DATE OF JUDGEMENT, DECISION, OR OTHER FINDINGS MADE, AND SANCTION IMPOSED. 22. Are you currently licensed as an insurance agent? If "yes," with what company or companies? Yes No 23. Please list any securities examinations that you have taken, the date(s) taken and the score(s) you obtained below. EXAMINATION(S) DATE(S) TAKEN SCORE(S) 24. APPLICANT HEREBY UNDERTAKES AND AGREES TO PROMPTLY FILE AMENDMENTS WITH THE COMMISSIONER AT ANY TIME WHEN THE INFORMATION PROVIDED HEREIN IS OR BECOMES INACCURATE OR INCOMPLETE IN ANY MATERIAL RESPECT AND TO PROMPTLY NOTIFY THE COMMISSIONER REGARDING ANY COMPLAINT OR ACTION INVOLVING SECURITIES FILED BY ANY PERSON AGAINST THE APPLICANT OR OF ANY DISCIPLINARY ACTION INSTITUTED OR TAKEN AGAINST THE APPLICANT BY THE EMPLOYING DEALER, THE FINRA OR ANY STATE, PROVINCIAL, OR FEDERAL SECU