Application For License For Agents Of New Hampshire Legal Entities (NH Issuer-Dealer) {D-2}

Form D-2 State of New Hampshire Department of State Bureau of Securities Regulation Application for License for Agents of New Hampshire corporations, partnerships, limited liability partnerships, limited liability companies and other legal entities Fee _________ Ck. No. ________ Each agent's personal statement must accompany this form. Agents' licenses expire December 31 unless revoked. Licenses will be sent to the dealer unless otherwise requested. The fee for each license must accompany this registration. Make checks payable to State of New Hampshire. THIS IS TO CERTIFY, that the persons named below, being suitable, have been appointed agents or salesperson(s) to sell the securities of (NAME OF CORPORATION OR OTHER LEGAL ENTITY) The said Corporation or other legal entity requests the Director to license them as agents or salesperson(s) in the state of New Hampshire. Dated at Signed By (OFFICIAL TITLE) this day of , Name (Give first name in full) Residence (Give full address) American LegalNet, Inc. www.FormsWorkFlow.com Sec. form D-2 9/2008