Application For Renewal Of Registration As An Agent Of An Issuer {S.D.4}

S.D.4.(1997) Agent File # COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING APPLICATION FOR RENEWAL OF REGISTRATION AS AN AGENT OF AN ISSUER (Print or Type) ________________________________________________________________________ _______________ Last Name First Name Middle Nameresiding at ____________________________________________________________ ___________, hereby Street Number City State Zip applies for a renewal of registration as an agent registered under the S ecurities Act, and reaffirms hisconnection with the issuer specified below: ________________________________________________________________________ _______________ (Name of Issuer) ________________________________________________________________________ _______________ (Principal Address of Issuer) ________________________________________________________________________ _______________ The address of the applicants place of business is to be entered her e if other than the principal address ofthe issuer. In order to assist in determining whether to grant the application, chec k below whether or not the applicanthas been involved in any of the following during the preceding registrat ion year. YES NO Has been convicted of felony or misdemeanor involving dishonesty? ( ) ( ) Has been sued for fraud, deceit or breach of trust? ( ) ( ) Has been adjudicated as bankrupt? ( ) ( ) Has any unsatisfied judgments against him? ( ) ( ) Has been denied a registration to sell securities? ( ) ( ) Has had a securities registration suspended or revoked? ( ) ( ) If the issuer is unable to answer any of the above with a (NO), the re newal cannot be processed until thesituation is discussed with the Division. CERTIFICATE The issuer named in the foregoing renewal application certifies that the information supplied is true andcorrect to the best of its knowledge and promises to notify the Commissi on promptly with respect to any change in information heretofore given. _________________________________________________________ Issuer Date _________________________________________________________ By (Signature) Title INSTRUCTIONS 1. Do not send separate $30.00 checks for each agent. Incorporate all fees into one check covering all renewals. Check to be made payable to the Treasurer of Virginia. 2. Should an investigation of the applicant be necessary, the Commission ma y require additional information. 3. If the applicant ceases to be connected with the issuer specified in the application, he and the issuer must promptly notify the Commission giving date of termination an d advising that the agents record is either clear or not clear. American LegalNet, Inc. www.USCourtForms.com