| Securities Lawyer's Deskbook
published by The University of Cincinnati College of Law |
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| State of ___________________________________ |
| County of ____________________________, ss: |
| the attached ____________________________________________________ dated |
| _____________________________________, 19 __________ for and on behalf of |
| ___________________________________ ; that he is the ____________________ |
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(Name of Company) |
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__________________________ |
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(Signature) |
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__________________________ |
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(Type or print name beneath) |
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(Title of Officer) |
| day of _________________________ , 19______. |
| [OFFICIAL SEAL] |
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My commission expires: ________________________ |
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