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(Name) <br /> <br />(Name) <br /> <br />(Address) <br /> <br />(Shareholder-:-Circle One) <br /> <br />- I <br /> I <br /> <br />(Name) <br /> <br />(Birthdate) <br /> <br />(Add~ess) <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />(Name) (Bit thd~te) <br /> <br /> (Address) (Shareholder/Officer - Circle One) <br /> <br />3) Are each of the officers and/or shareholders named above citizens of <br /> <br />the United States? ~/~ <br /> <br />I <br />I <br /> <br />If no, state the circuustances for each officer/shareholder who <br />citizen. <br /> <br />is not a <br /> <br />If naturalized, state date and place of naturalization. <br /> <br />4) <br /> <br />Give the full name and address of each officer's/shareholder's spouse. <br /> <br />Officer/Shareholder Spouse Add r es s <br /> <br />Page 2 of 8 <br /> <br /> <br />