State of New Hampshire
Department of State
Bureau of Securities Regulation
No license will be issued
until ALL blanks in this
form are properly filled out.
Personal Statement of Agent
(Give Full Name)
(Number and Street and/or P.O. Box)
(Town or City)
Current Home address
Have you read the New Hampshire law regulating the sale of securities?
Residence for past five years
Occupation for prior five years
If employed, give name and address of employer(s)
If member of firm, give firm name and names of partners
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
15. State briefly the general plan and method of selling securities, whether by person solicitation, correspondence
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.
Subscribed and sworn to before me this
Date of expiration of commission
Sec. form D-3 9/2008