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2
of
3
2.
been an officer, director, partner or employee of any corporation, partnership or other
organization which, to your knowledge, has engaged in any transaction described in (a) above
with the Corporation;
Yes____
No____
3.
been interested monetarily, directly or indirectly, in any organization doing business with the
Corporation (unless as a holder of less than 5% of the voting securities issued by a corporation
whose securities are publicly traded); and
Yes____
No____
4.
been a recipient, directly or indirectly, of any payments or material gifts of any kind from or on
behalf of any organization doing business with the Corporation (unless by way of dividend or
interest payments made by a corporation whose securities are publicly traded)?
Yes____
No____
B.
Is any transaction contemplated, involving you or any member of your immediate family,
which, if consummated, would be described in answer to any of the preceding items?
Yes____
No____
C.
Are you aware of any interest or activity on your part, or on the part of any member of
your immediate family, which is in conflict with the interests of the Corporation?
Yes____
No____
(Please sign)
Title
Dated
