1. Individual Recommended:� _________________________________________________________________

��� Business Address:� _________________________������ Home Address: _______________________________

��� _________________________________________��� _____________________________________________

��� _________________________________________��� _____________________________________________

��� Telephone Number:� ________________________����� Telephone Number:��___________________________

��� Category:��� Bank Dealer Representative�������� Securities Firm Representative����� Public Member

2. Educational and Professional Background

��� Professional:� ____________________________________________________________________________

��� _______________________________________________________________________________________

��� _______________________________________________________________________________________

��� Educational: ��____________________________________________________________________________

��� ________________________________________________________________________________________

��� ________________________________________________________________________________________

��� Associations: �____________________________________________________________________________

��� ________________________________________________________________________________________

��� ________________________________________________________________________________________

3. Proposer:� _______________________________________________________________________________

��� ________________________________________________________________________________________

��� ________________________________________________________________________________________

4. Associated Person under Securities Exchange Act of 1934: ��_______________________________________

��� ________________________________________________________________________________________