Agent Licenses Form For Issuer Application For Renewal Page 3
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4S.551.32(7) Wis. Stats. and 4.07(1)c Wis. Adm. Code
Applicant hereby makes application to the DFI-Division of Securities for renewal of the securities
agent licenses of the following individuals, authorizing said individuals to represent the undersigned
issuer in the sale of securities in Wisconsin. The application is accompanied by the $30.00 filing fee
for each individual named below, and the applicant agrees to pay any expenses reasonably attributable
to any investigation or examination of the agent(s) that the Administrator may find necessary with
respect to this application. The undersigned issuer takes responsibility for the acts of the agent(s) in
the sale of securities in this state. If, prior to the end of the license period, any of the agents named
below cease to represent the issuer in the sale of securities or the issuer completes its offering(s) in
Wisconsin, the applicant agrees to make application for withdrawal of said agent(s) securities licenses
pursuant to Wis. Adm. Code section Sec. 4.08(2):
Last Name, First Name, &
List Issuers Currently
Middle Initial
Representing
1.
________________________
________________________________
2.
________________________
________________________________
3.
________________________
________________________________
4.
________________________
________________________________
5.
________________________
________________________________
6.
________________________
________________________________
7.
________________________
________________________________
8.
________________________
________________________________
9.
________________________
________________________________
10.
________________________
________________________________
DFI/DOS/AIR (R 7/00)
05/19/03
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