Personal Statement Of Agent (NH Issuer-Dealer) {D-3}

Form D-3 STATE OF NEW HAMPSHIRE No.______________ DEPARTMENT OF STATE Recd____________ No license will be BUREAU OF SECURITIES REGULATION Appd____________ issued until ALL Fee______________ blanks in this form Granted__________ are properly filled out. Personal Statement of Agent 1. Name D.O.B. SS No. (Give Full Name) 2. Business address (Street and Number or P.O. Box) (Town or City) (Zip No.) Current Home address 3. Have you read the New Hampshire law regulating the sale of securities? 4. Residence for past five years 5. Present occupation How long? 6. Occupation for prior five years 7. If employed, give name and address of employer(s) 8. If member of firm, given firm name and names of partners 9. What other business do you intend to carry on? 10. How many years experience in selling securities have you had? 11. By whom were you employed? 12. In what other states have you ever applied for a securities license? 13. In what other states are you registered or licensed? 14. In what states, if any, have you been refused a securities license or have been subject to revocation or suspension? 15. State briefly the general plan and method of selling securities, whether by person solicitation, correspondence or otherwise 16. Name of last employer and type of work performed I desire to be licensed as an agent of (GIVE CORPORATE NAME) 17. For the purpose of complying with the laws of New Hampshire relating to either the offer or sale of securities in New Hampshire, I irrevocably appoint the Secretary of State of New Hampshire and the successors in such office, my attorney upon whom may be served any notice, process or pleading in any action or proceeding against me arising out of or in connection with the offer or sale of securities, or out of the violation, or alleged violation, of the laws of New Hampshire. I consent that any such action or proceeding against me may be commenced in any court of competent jurisdiction and proper venue by service of process upon the appointee as if I were a resident of, and had been lawfully served with process, in New Hampshire, I request that a copy of any notice, process or pleading served hereunder be mailed to my current residential address as reflected in this form or any amendment thereto. Signed Notarized: STATE OF COUNTY OF Subscribed and sworn to before me this day of , Notary Public Date of expiration of Commission sec. form D-3 v1.1