FORM FOR APPLICATION FOR REGISTRATION, ANNUAL REPORT, OR AMENDMENT OF REGISTRATION

STATE OF MINNESOTA DEPARTMENT OF COMMERCE REGISTRATION AND LICENSING DIVISION This is submitted for (check one only): Application for Registration (Franchise) ( ) Annual Report ( ) Amendment of Registration of _ ( ) (date) (For use by the Department of Commerce) File No.: _ Fee: $ _ Fee Paid: _ (To be completed by the applicant) Receipt No.: _ Initial Review: _ Date of Application Effective Date: _ _ Orders Issued: _ (To be completed by the applicant) Examiners Initials: _ Name, telephone number, and address of person to whom questions concerning this statement should be directed.