Michigan Securities Commission

(Department of Real Estate.)

To the Michigan Securities Commission, Lansing, Michigan:

In compliance with Act No. 306 of the Public Acts of 1919,

I (we)..................................................................................................

hereby make application for a license authorizing me (us) to transact the business of a Business Chance Broker for 1921 in compliance with the law regulating and licensing such business within the State of Michigan, and tender the FEE of $10.00 herewith.

1. Name of applicant....................................................................

(If firm, give names of members; if partnership, give names of partners; if co-partnership, association or corporation, give officers.)

2. Business address (street and number)................................

(City or town) ........................................................................

(If more than one office, give address of those other than main one here.)

3. Residence (street and number)..............................................

(City or town).........................................................................

4. If a firm, partnership or corporation designate member of said firm, partnership or corporation to receive salesman's card under the license......................................................................

5. What has been your business or occupation for the past five years? Give places where continuous for sixty days or more ..................................................................................................

6. Give reference other than endorsers for each place stated in question five......................................................................

7. Have you been in any litigation over real estate during the past year?....................................................................................

State nature of complaint............................................................

Signed (applicant)........................................

(If applicant is firm or partnership, signer must give his relation to firm or partnership; if corporation, application must be signed by proper officers.)

Sworn to and subscribed before me, a notary public in and for the county of........................, State of Michigan, this............

day of...................................., 192.........

(Seal) ...........................................................................................

My commission expires................................................................

Recommendation (Two Endorsers Required.)

We, the undersigned, who are, and have been for a period of a year past, owners of real estate in the county of................,

Michigan, do respectfully recommend for your consideration the application of........................................for a license as a real estate broker.

We do hereby certify that we are well acquainted with the applicant (s) and also certify that he (they) has (have) a good reputation for honesty, integrity and fair dealing, and that we are satisfied that he (they) is (are) worthy of the license for which he (they) applies (apply).

Name ..............................................................................................

Address.........................................................................................

Name..............................................................................................

Address..........................................................................................