Agent Licenses Form For Issuer Application For Renewal
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State of Wisconsin
Department of Financial Institutions
Lorrie Keating Heinemann, Secretary
Jim Doyle, Governor
AGENT LICENSES FOR ISSUER
APPLICATION FOR RENEWAL
This form is required by section 4.07(1)c, Wis. Adm. Code to renew the licenses of
persons offering securities of the issuer to the public. Failure to comply within 30 days
may result in fines, penalties or revocation of the license of all agents.
SEE SUPPLEMENTAL INFORMATION ON PAGE 4
1.
Exact name, principal business address, mailing address (if different) and telephone number of
issuer:
(a)
Full name of issuer:
_________________________________________________________________
(b)
Name under which business is conducted:
_________________________________________________________________
(c)
Address of principal place of business:
_________________________________________________________________
(d)
Mailing address:
_________________________________________________________________
(e)
Telephone number:
_________________________________________________________________
2.
Branch offices of issuer located in Wisconsin:
Office Address
Name of Person In Charge
______________________________
_____________________________
______________________________
_____________________________
Division of Securities
th
Mail: PO Box 1768 Madison, WI 53701-1768
Courier: 345 W. Washington Ave. 4
Floor Madison, WI 53703
Voice: (608) 266-1064
Fax: (608) 264-7979
TTY: (608) 266-8818
Internet:
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