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| 1a |
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| 1b |
- Issuers IRS identification number
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| 1c |
- Issuers SEC file number, if any
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- Instruction: The person filing this notice should contact the
issuer to obtain the IRS Identification Number and the SEC File Number
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| 1d |
- Issuers address, including zip code
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| 1e |
- Issuers telephone number, including area code
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| 2a |
- Name of person for whose
account the securities are to be sold
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| 2b |
- Such persons IRS
identification number, if such person is an entity
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| 2c |
- Such persons relationship to the issuer
- e.g., officer, director, 10% stockholder, or member of
immediate family of any of the foregoing
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| 2d |
- Such persons address, including zip code
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| 3a |
- Title of the class of
securities to be sold
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| 3b |
- Name and address of each broker through whom the securities are to be offered or each market maker who is acquiring the securities
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| 3c |
- Number of shares or other
units to be sold
(if debt securities, give the aggregate face amount)
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| 3d |
- Aggregate market value of
the securities to be sold
as of a specified date within 10 days prior to filing of this notice
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| 3e |
- Number of shares or other
units of the class outstanding,
or if debt securities the face amount thereof outstanding,
as shown by the most recent report or statement published by the issuer
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| 3f |
- Approximate date on which
the securities are to be sold
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| 3g |
- Name of each securities
exchange, if any, on which the securities are intended to be sold
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Furnish the following information with respect to
the acquisition of the securities to be sold and with respect to the payment of
all or any part of the purchase price or other consideration therefor:
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Instructions: If the securities were purchased
and full payment therefor was not made in cash at the time of purchase, explain
in the table or in a note thereto the nature of the consideration given. If the
consideration consisted of any note or other obligation, or if payment was made
in installments describe the arrangement and state when the note or other
obligation was discharged in full or the last installment paid.
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