Looking for a Michigan Legal Forms And Templates? Download it for free!

Fis 0532 5/04 Business History Form - Michigan Department Of Labor & Economic Growth

FIS 0532 (5/04) Office of Financial and Insurance Services

This form is issued under Act 265, PA 1964, as amended. You

must file this form as required under Section 304 of the Act.

Business History

One of these forms is to be completed by each Officer and Director

Broker-Dealer’s / *Issuer’s name

Name of Individual

Present Home Address

Position with above

Will you be active full time or part time in affairs of above?

*If issuer, present holdings of securities of this issuer

*If issuer, amount of this issue you intend to purchase

What will be your total annual salary or compensation

Date of Birth

Place of Birth

U.S Citizen

YES

Education (State fully amount of technical or professional training, if any, and where obtained)

Give below or attach a chronological accounting of your time from completion of formal education to the present time. Do not list positions

held less than six months. If inactive at any time for more than six months, state when, for how long, and for what reasons.

Beginning

Ending

Business of

Position

Name and Address of Employer

Date

Employer

Held

RETURN COMPLETED APPLICATION TO:

Our Street Address:

Office of Financial and Insurance Services

Securities Section

611 W. Ottawa Street, 3

Floor

P.O. Box 30701

Lansing, MI 48933

Lansing, MI 48909-8201

Fis 0532 5/04 Business History Form - Michigan Department Of Labor & Economic Growth