Notification of Changes for Business Entity
General Information
Business Entity Name:	BRISTLECONE NEVADA
Incorporation / Formation Date:
FEIN:	26-3258020
Ohio License Number:	1132801
NPN:	11741141
DBA / Trade Name:
State of Domicile:	NV
County:	LAS VEGAS
Business Address
Address 1:	9075 W DIABLO DR
Address 2:
City:	LAS VEGAS
State:	NV
Zip:	89148
Phone:	(800) 638-5216
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	9075 W DIABLO DR
Address 2:
City:	LAS VEGAS
State:	NV
Zip:	89148
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BRENT TRAVIS HARPER	DESIGNATED RESPONSIBLE PRODUCE	1156778	YES		09-06-2017

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)	NO
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?	NO
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	CSC
Title:	AUTHORIZED SUBMITTER
Phone Number:	8009279800
Email Address:	BLINSUR@CSCGLOBAL.COM