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I <br />I <br />I <br /> <br />(Name) (Birthdate) <br /> <br />(Name) (Birthdate) <br /> <br />I (Address) <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />I <br />I <br /> <br />3) Are each of the officers and/or <br />the ~nited states?--X/~3 <br /> <br />shareholders named above citizens of <br /> <br />If no, state the circumstances for each officer/shareholder who is not a <br />citizen. <br /> <br />If nat~ralized, state date ~-~ plaoe of rmturalization. <br /> <br /> 4) <br />I Officer/Shareholder ~ Spouse~ <br /> <br />Give the full name and address of each officer's/shareholder's spouse. <br /> <br />Address <br /> <br />Pa~e 2 of 8 <br /> <br /> <br />