Were shares bought in your name: Yes No

 If no, list the name and address of the person or entity that bought shares:

If shares were purchased by an entity, are you an officer or director:
Yes No

Did you purchase the stock because of an analyst's recommendation?
Yes No

If yes, what was the name of the analyst and what firm did they work for:


Did you rely on the the advice of a stockbroker when purchasing this stock?
Yes No

If yes, do you believe the stockbroker recommended unsuitable investments or concentrated your investments in too few stocks
Yes No

If you believe you received unsuitable advice, please explain why:

How many shares of stock were purchased:

What was dollar amount of shares purchased:

For all purchases, please list date, price and number of shares bought:

For all purchases, please list date, price and number of shares sold:

Other Information:

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