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(Nm~e) (Birthdate) <br /> <br />I <br />I <br /> <br />(Name) <br /> <br />(Address) <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />(Bit thdate) <br /> <br />(Adckess) <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />(Name) <br /> <br />(Birthdate) <br /> <br />(Address) <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />I <br />! <br /> <br />3) Are each of the officers and/or shareholders named above citizens of <br /> <br />the United States? . U~ <br /> <br />I <br />i <br /> <br />If no, state the circ~'tances for each officer/shareholder who <br />citizen, l~ / ~ I' <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 />Of ricer/Shareholder Spouse Addr ess <br /> <br />Page 2 o~ 8 <br /> <br /> <br />