NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): Yes _________ No __________ If Yes, please describe: _________________________________________________________ _________________________________________________________ _________________________________________________________ *If Subscriber is a Registered Representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by Article 3, Sections 28(a) and (b) of the Rules of Fair Practice. _________________________________ Name of NASD Member Firm By: ______________________________ Authorized Officer Date: ____________________________
NASD AFFILIATION. Contributor represents severally that neither it nor any affiliate of Contributor is a member, affiliate of a member or person associated with a member of the National Association of Securities Dealers, Inc. ("NASD"). Contributor further represents severally that neither it nor any of its affiliates owns any stock or other securities of any NASD member not purchased in the open market, or has made any outstanding subordinated loans to a NASD member. (A company or natural person is presumed to control a member of the NASD and is therefore presumed to constitute an affiliate of such member if the Company or person is the beneficial owner of 10% or more of the outstanding securities of a member which is a corporation. Additionally, a natural person is presumed to control a member of the NASD and is therefore presumed to constitute an affiliate of such a member if such person has the power to direct or cause the direction of the management or policies of such member.)
NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one)? YES NO If yes, please describe:** **If Subscriber is a Registered Representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by Article 3, Sections 28(a) and (b) of the Rules of Fair Practice. Name of NASD Member Firm By: Authorized Officer—Signature Authorized Officer—Printed Name Date: , 2001
NASD AFFILIATION. The undersigned is affiliated or associated, directly or indirectly, with a National Association of Securities Dealers, Inc. ("NASD") member firm or person. Yes______ No______ If yes, list the affiliated member firm or person: ____________________ _______________________________________________________________________ _______________________________________________________________________ Your relationship to such member firm or person: ______________________ _______________________________________________________________________ _______________________________________________________________________
NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): Yes _________ No __________ If Yes, please describe: __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________
NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): YES NO If Yes, please describe: _________________________________________________________ _________________________________________________________ _________________________________________________________ *If subscriber is a Registered Representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by the NASD Conduct Rules. _________________________________ Name of NASD Member Firm By: ______________________________ Authorized Officer Date: ____________________________
NASD AFFILIATION. Are you associated with an NASD member firm? (Please check one) YES_____ NO_____ If Yes, please describe:
NASD AFFILIATION. The undersigned is affiliated or associated, directly or indirectly, with a National Association of Securities Dealers, Inc. (“NASD”) member firm or person. Yes o No ý If yes, list the affiliated member firm or person: Your relationship to such member firm or person:
NASD AFFILIATION. Please state whether you or any of your associates or affiliates (which includes your spouse, in-laws and children or parents): (i) are a member or a person associated (including as an employee, officer, director, partner) with a member of the National Association of Securities Dealers, Inc. (the "NASD"), (ii) are an owner of stock or other securities of an NASD member, (iii) has made a subordinated loan to any NASD member, or (iv) a relative or member of the same household of any person meeting the description set forth in clauses (i) through (iii) above. _____ _____ Yes No If you marked yes above, please briefly describe the NASD relationship below: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ SECTION B: ACCREDITED INVESTOR STATUS B1. Please check one or more of the following definitions of "accredited investor," if any, which applies to you. If none of the following applies to you, please leave blank.
NASD AFFILIATION. Are you affiliated or associated with an NASD member firm (please check one): Yes _________ No __________ If Yes, please describe: _________________________________________________________ _________________________________________________________ _________________________________________________________ *If Subscriber is a registered representative with an NASD member firm, have the following acknowledgment signed by the appropriate party: The undersigned NASD member firm acknowledges receipt of the notice required by Article III, Sections 28(a) and (b) of the Rules of Fair Practice. _________________________________ Name of NASD Member Firm By: ______________________________ Authorized Officer Date: ____________________________ Part V REGISTRATION QUESTIONNAIRE The following questions in this Part V are specifically intended to provide information to the Company for the Company's use in the preparation of the Registration Statement contemplated by the Subscription Agreement and for specific inclusion in such Registration Statement.
