Connecticut Sales Agent Broker-Dealer Licensing Questionnaire {SABDQ}

CONNECTICUT SALES AGENT/BROKER-DEALER LICENSING QUESTIONNAIRE (Rev. 6/2003) What This Form Does The Connecticut Uniform Securities Act requires broker-dealers and agent s of issuer who transact business in or from the state to be registered. To help us with our lice nsing function, this form elicits information on broker-dealers and agents of issuer involved in public an d private offerings. 1. Issuers Name: 2. Answer this Question Only If the Issuer WILL Use a Broker-dealer Firm fo r Connecticut Sales a. Broker-dealers name and CRD number: b. Broker-dealers address: 3. Answer this Question If the Issuer Will NOT Use a Broker-dealer Firm for Connecticut Sales a. Name the individual who will represent the issuer in offering or sell ing securities in Connecticut. Corporations, partnerships and LLCs are not individuals. b. The individuals CRD number (if any) or taxpayer identification num ber is: c. Individuals address: d. Individuals position with the issuer: [ ] Employee [ ] Partner [ ] Officer [ ] Director [ ] Managing Member [ ] Officer of corporate general partner [ ] Other (e.g. finder) Specify e. Is he or she otherwise in the business of effecting securities transa ctions? [ ] Yes [ ] No f. If the individual is a partner, officer, director or managing member of the issuer or an officer of a corporate general partner, will the individual receive any direct o r indirect remuneration related to offers or sales of the securities in or from Connecticut? [ ] Yes [ ] No g. Will the individual be applying for agent of issuer registration? [ ] Yes [ ] No h. If the individual is a broker-dealer agent who has or may receive sal es compensation in connection with the sale of the issuers securities, enclose a copy of t he broker- dealers written approval required by Section 36b-31-6e(d) of the Regu lations of Connecticut State Agencies. [ ] Copy Enclosed [ ] Not Applica ble I certify that the foregoing responses are true, accurate and complete. (Sign here) Print name of signatory, and then date this form: Position with Issuer: American LegalNet, Inc. www.USCourtForms.com