Agent Licenses Form For Issuer Application For Renewal Page 4
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4S.551.32(7) Wis. Stats. and 4.07(1)c Wis. Adm. Code
Applicant certifies that this application is true, correct, and complete, and agrees that any material
changes in any statements made herein or in any exhibits attached hereto shall be reported to the
Administrator within 30 days after the occurrence of such changes. Applicant agrees to comply with
the provision of the Wisconsin Uniform Securities Law and all rules and orders of the Administrator
thereunder. All statements made herein and exhibits attached hereto shall be deemed representations
made to the Administrator in connection with any determination made or license issued with respect to
this application.
Dated this ___________ day of _________________, 20 ____.
_________________________________________
Name of Issuer
Reset Form
By
_________________________________________
Signature and Title
SUPPLEMENTAL INFORMATION
1.
The expiration date of a securities agent license to represent an issuer under the Wisconsin
st
Uniform Securities Law is July 31
, and the license renewal form must be received by the
st
Administrator’s office not later than July 1
. If the renewal form is not filed by that date, the issuer
will be subject to a late filing fee, which is $100 per agent.
2.
Answer all questions or insert “Not Applicable”; reference to prior applications is not acceptable.
3.
Be sure to include each agent’s social security number.
4.
All exhibits attached hereto should be on 8-1/2 x 11 in. Paper.
Questions, concerning this application may be directed to Licensing and Compliance Bureau of the
Division of Securities at (608) 266-2139.
(This space reserved for the use of the Division of Securities)
Filing Fees $ __________
Receipt Number __________ Date Received ___________
DFI/DOS/AIR (R 7/00)
05/19/03
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