Affidavit For Waiver Of Examination {S.A.3}

S.A.3 (Rev. 7/99) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING AFFIDAVIT FOR WAIVER OF EXAMINATION Pursuant to 21 VAC 5-80-130 B State of _____________________________________ County/City of ________________________________, to wit: The undersigned, having been duly sworn, deposes and says: 1. My name is _____________________________________________________________ _. 2. My CRD number is _______________________________________________________ _. 3. The name of the investment advisory with which I am, or will be connecte d is __________ ________________________________________________________________________ . 4. The CRD number of this investment advisor is ___________________________ _______. 5. I am, and have been for at least the five years immediately preceding the date on which my application for registration was filed, actively engaged in the inves tment advisory business. 6. I have been for at least the two years immediately preceding the date on which my application for registration was filed the president, chief executive, c hairman of the board of directors, or managing partner, member, trustee or similar functionar y, of an investment advisor actively engaged in the investment advisory business. 7. The investment advisor(s) referred to in subdivision 6, above, have, o r had during my tenure as president, chief executive officer, chairman of the board of d irectors, or managing partner, member, trustee or similar functionary, at least forty million dollars under management. 8. I have read and am familiar with the investment advisor and investment a dvisor representative provisions of the Virginia Securities Act ( 13.1 501 et seq. of the Code of Virginia) and provisions of 21 VAC 5-80-10 - 240 of this Commission s Securities Act Rules. 9. None of the questions in Item 22 (disciplinary history) on my Form U-4 have been, or need be, answered in the affirmative. _____________________________________ Signature of the Affiant Subscribed and sworn to before me, a Notary Public, this _______________ __________ day of ______________________________, _______. _______________________________(SEAL) Signature of the Notary Public My commission expires:_________________________ INSTRUCTIONS This form must be filed with the Division of Securities and Retail Franc hising. Form U-4 (or any amendment) and any required fee must be filed with the NASA/NASD Centra l Registration Depository system. American LegalNet, Inc. www.USCourtForms.com