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of14|ExecutiveFirstPrivateCompanyPortfolioApplication12/2015

Executive First® Private Company Portfolio Application

NOTICE: THECOMPLETIONOFTHISAPPLICATIONDOESNOTBINDTHE INSURERTOOFFER,NORTHEAPPLICANTTOPURCHASEINSURANCE. THE INSURERWILL RELY UPON THE ACCURACY AND COMPLETENESS OF THIS APPLICATION FOR INSURANCE, INADDITIONTOINFORMATIONSUPPLIEDVIAATTACHMENT,ANDINPUBLICFILINGS.THISAPPLICATIONWILLFORMTHEBASISOF,ANDBECOMEPARTOF,ANYRESULTINGPOLICY. COVERAGEUNDERANYSUCHPOLICYWILLBEONACLAIMS-MADEBASIS. NOCOVERAGEWILLEXISTFORCLAIMSFIRSTMADEAGAINSTANINSUREDAFTERTHEENDOFTHEPOLICYPERIODUNLESSANDTOTHEEXTENTTHATANEXTENDEDREPORTINGPERIODAPPLIES. DEFENSECOSTSWILLREDUCEANDMAYEXHAUSTTHELIMITOFLIABILITYUNDERSUCHPOLICY,ANDWILLALSOBEAPPLIEDAGAINSTTHERETENTION.Instructions: Applicantshouldcompletethesectionsof theApplicationrelevant to thespecificcoveragesrequested. Theterm“Applicant”shallmeantheParentOrganizationapplyingforthisinsuranceandallofitsSubsidiaries.

I.GeneralInformation

1.NameofApplicant:

AddressofApplicant:

Street:______________________________________________________________________________________________City:______________________________________________State:____________________________Zip________________

2.NatureofOperationsandPrimarySICCode:

3.ArethereanySubsidiarieswithoperationsthataredissimilartowhatislistedabove?

Ifso,pleasedescribe.

Yes No

______________________________________________________

4.ApplicantWebSite(s):

5.YearsofContinuousOperation:


6.IstheApplicantpublicly-heldorapublicreportingcompanyundertheSecuritiesExchangeActof1934asamended?

Yes No

7.a.HastheApplicantinthelast12monthscompletedany:i)Merger,acquisitionordivestment?ii)Restructuring,reorganizationorarrangementwithcreditors?iii)Bankruptcyfiling?

Yes NoYes NoYes No

b.IstheApplicantanticipatinganyoftheeventsshownin7.a.aboveinthenext12months?

Yes No

Ifanyquestionaboveis“Yes,”pleaseattachdetails.

II.Applicant’sFinancialInformation:PleasecompletethebelowgridfortheApplicant’smostrecentfiscalyearending______________Month_______________Year

TotalRevenues

$

NetIncomeor NetLoss

$

CashflowfromOperatingActivitiesPositive Negative

$

CurrentAssets

$

TotalAssets

$

CurrentLiabilities

$

LongTermDebt

$

TotalLiabilities

$

RetainedEarningsPositive Negative

$

Shareholder’sEquityPositive Negative

$

8.Willmorethan50%ofthetotallong-termliabilitiesmaturewithinthenext18months?If“Yes,”pleaseprovidedetailsbyattachment. Yes No

PleaseprovidetheApplicant’smostrecentannualfinancialstatements(auditedifavailable).


III.InsuranceInformation:Pleaseplacean“X”intheboxbelowforeachcoveragerequested.“ContinuityDate”meansthepolicyinceptiondateforwhichamainformapplicationwasmostrecentlycompletedandcoveragecontinuallymaintained.Ifthereisnocurrentcoverage,pleaserespond“N/A”inthe“LimitCurrentlyPurchased”field. CoverageRequested LimitRequested Limit

CurrentlyPurchased

RetentionCurrentlyPurchased

ContinuityDate

CurrentInsurer

DirectorsandOfficersLiability

EmploymentPracticesLiability

FiduciaryLiability

EmployedLawyersLiability

Crime

* *

*IfcurrentCrimeprogramhasvaryinglimitsandretentions,pleaseprovidedetailsbyattachment.

9.Hasanypriorinsurermadeanypayments,beensentnoticeofaclaimorpotentialclaim,ornon-renewedanymanagementliability,crimeorsimilarinsuranceanytimeinthepast24months?If“Yes,”pleaseprovidedetailsbyattachment.

Yes No

FullycompletetheCoverageSectionQuestionsforeachcoveragethatisbeingrequested.


DirectorsandOfficersLiabilityCoverageSectionQuestionsPlease answer the following questions if Directors and Officers Liability coverage is being requested

Ownership

1.PercentofoutstandingvotingsharesorvotingrightsoftheApplicantownedby,directlyorindirectly,theDirectorsandOfficersoftheApplicant

%

2.Listanyshareholdersthatownorcontrolmorethan5%oftheApplicantthatarenotDirectorsorOfficersoftheApplicant(useadditionalsheets,ifnecessary):

VotingShares

Owned/Controlled

%

%

%

%

3.Totalnumberofvotingshareholders

Transactions&Operations4.Withinthelast18months,hastheApplicanthadorattempteda:a)Publicorprivateofferingofdebtorequitysecurities,includinganyofferingunder

theJumpstartOurBusinessStartupsAct(JOBSAct)?b)Changeindirectorsorseniorofficers?

Yes No

Yes No

5.Withinthenext18months,doestheApplicantanticipateany:

a) PublicorprivateofferingofequitysecuritiesincludinganyofferingundertheJumpstartOurBusinessStartupsAct(JOBSAct)?

b) Publicorprivateofferingofdebt?c) Saleofsecurities,services,goodsorproductsforthepurposeoffundingApplicant

operationsorcapitalthroughsocialnetworking,crowdfunding,crowdsourcingorsimilarmethod?

Yes No

Yes No Yes No

6.HastheApplicant,atanytimewithinthepastfiveyears,derivedmorethan10%ofits

annualrevenueorfundingfromfederal,state,local,foreignorothergovernmentalorquasi-governmentalsources?

Yes No


7.DoestheApplicanthaveanydirectorindirectinsuranceoperations?

Yes No

8.DoestheApplicantperformanyprofessionalservicesforafee?

Yes No

9.IstheApplicantformedasapartnershiporlimitedpartnershipordoesitoranyofits

SubsidiariesactasaGeneralPartnerforanotherorganization?

Yes No

Iftheanswertoanyquestionaboveis“Yes,”pleaseattachdetails.

PastActivities

10.HastheApplicantoranypersonproposedforcoveragebeenthesubjectof,orbeen

involvedin,anyofthefollowingduringthepastfiveyearsa)Anti-trust,copyrightorpatentlitigation?b)Deceptivetradepracticesorconsumerfraud?c)Civil,criminaloradministrativeproceedingallegingviolationofanyfederalorstate

securitieslaws?d)Anyothercriminalactions?

Yes No Yes No Yes No

Yes No

11.OtherthanthoseidentifiedinQuestion10above,hasanypersonorentityproposedforcoveragebeenthesubjectof,orinvolvedin,anylitigation,administrativeproceeding,demandletter,orformalorinformalgovernmentalinvestigationorinquiry?

Yes No

Iftheanswertoanyquestionaboveis“Yes,”pleaseattachdetails.


EmploymentPracticesLiabilityCoverageSectionQuestionsPlease answer the following questions if Employment Practices Liability coverage is beingrequested

EmployeeCount1. Domestic(U.S.)Employees: CurrentYear PriorYear

a) Full-time b) Part-time(includingleasedandseasonal) c) Independentcontractors d) Unpaidinterns/apprentices e) Numberorpercenthourlyemployees f) Numberofemployeesina-cabovelocatedinCA g) Numberofemployeesina-cabovelocatedinFL,MS,NJ,NY,TN,WV

2. Foreign(nonU.S.)Employees: 3. ChangesinWorkforce:

a) HastheApplicanthadduringthepast12months(oristheApplicantplanninginthenext12months)anylayoffs,officeorfacilityclosures,orreductionsinworkforce?

b) Havemorethan25%oftheApplicant’sofficersorseniormanagementleftthecompanyinthepast18months?

Yes No

Yes No

Iftheanswerto3.a)orb)aboveis“Yes,”pleaseattachdetails.U.S.SalaryRanges4. EmployeeSalaryRanges: %ofEmployeesinRange

CurrentYear%ofEmployeesinRangePrior

YearUpto$50,500 $50,501to$120,000 Over$120,000

PoliciesandProcedures

5. DoestheApplicantpublishanemployeehandbookanddistributeittoevery

employee?

Yes No

6. DoestheApplicanthavewrittenproceduresinplaceregarding:

a) EqualEmploymentOpportunity?b) Discrimination?c) SexualHarassment?d) Handlingcomplaintsofsexualharassmentordiscrimination?

Yes No Yes No Yes No Yes No

Iftheanswertoanyquestionaboveis“No,”pleaseattachdetails.


AdditionalquestionforApplicantswithmorethan250employees

7. Areallterminationsreviewedbya) HumanResources?b) Counsel(Internalorexternal)?

Yes No Yes No

8. Isthereafull-timehumanresourcesmanagerordepartment?

Yes No

9. DoestheApplicantconducttrainingregardingdiscriminationandsexualharassmentpoliciesandprocedures?

Yes No

10. Doeslaborrelationscounselreviewemploymentpolicies,procedures,andmaterialatleastannually?

Yes No

11. IftheApplicantisorhasbeenafederalcontractor,hastheApplicantbeensubjecttoanOFCCP(OfficeofFederalContractCompliancePrograms)audit?

Yes No Not Applicable

12. DoestheApplicanthavewrittenproceduresinplaceregarding:a) Employmentatwill?b) ADA(AmericanswithDisabilitiesAct)accommodations?

Yes No Yes No

13. Arecriminalbackgroundchecksusedinthehiringprocess? Yes No

Iftheanswerto7–12is“No,”or13is“Yes,”pleaseattachdetails.

PastActivities

14.Inthepastthreeyears,hasanyApplicant,inanycapacity,beeninvolvedinanyofthefollowingmatters?

a)EEOC(EqualEmploymentOpportunityCommission)orothersimilaradministrativeproceeding,regulatoryactionorinvestigation

b)Employment-relatedcivilsuitorclaim

Yes No

Yes No

If“Yes,”pleaseattachdetails.

HumanResourcesManager,orHumanResourcescontactinformation(forHelplineServices):____________________________________________________________________________________________________________________________________________________________________________________________________


FiduciaryLiabilityCoverageSectionQuestionsPlease answer the following questions if Fiduciary Liability coverage is being requested

Planinformation:InthetablebelowpleaselistthenamesandtypesoftheApplicant’semployeebenefitplan(s).Attachadditionalpages,ifneeded.TypeofPlan:DC=DefinedContributionPension(forexamplea401(k)plan),DB=DefinedBenefitPension,W=Welfare,O=Other

NameofPlan(asitappearsonForm5500,ifapplicable)

CurrentMarketValueofAssets(ifapplicable)

TypeofPlan

IsanyplananESOPoratanytimeinthepast36monthshaveassets

beenheldorpermittedtobeinvestedin

EmployerSecuritiesorisanysuchinvestment

expectedinthenext12months(Yes/No)*

TotalNumberofParticipants

NameofInvestmentManager**

*ESOPmeansEmployeeStockOwnershipPlanandEmployerSecuritiesmeanssecuritiesoftheApplicant,theparentoftheApplicant,anycompanythatisacquiredinwholeorinpartbytheApplicant,oranyformerparentofanycompanythatisacquiredinwholeorinpartbytheApplicant.**“InvestmentManager”isthepartygrantedcontroloforauthoritytoinvestplanassets.


1.CurrentmarketvalueofassetsofallSponsoredPlansforwhichcoverageisrequested: $___________________

2.Inthepast24months,hasanyamendment(s)toanyplanbeenmadeorconsideredthathasresultedin,ormayresultin,areductionofbenefits,includingbutnotlimitedtoachangeintheformulaforcalculatingbenefits,acessationofmedicalorpost-retirementbenefits,oranincreaseinparticipants’ortheplan’sshareofcosts?

Yes No

3.Hasanyplanorpartofaplan,beentransferred,merged,orterminatedorisanysuchactivityunderconsideration? Yes No

4.Arethereanyoverdueemployercontributionsforanyplan,orhasarequestforawaiverofcontributionsbeenmadeorcontemplatedforanyplan? Yes No

5.ArealldefinedbenefitplansadequatelyfundedinaccordancewithERISAorapplicablesimilarcommonorstatutorylawoftheUnitedStates,Canada,theUnitedKingdom,oranystateorotherjurisdictionanywhereintheworld?

Yes No

Not Applicable

Iftheanswerto2,3or4is“Yes”ortheanswerto5is“No,”pleaseattachdetails.

PastActivities6.Inthepastthreeyearshastherebeenanyclaim,lawsuitorregulatoryactionagainst,or

regulatoryinvestigationorinquiryofanypersonorentityproposedforcoverage,arisingoutofanyplanorallegingaviolationofERISAorEmployeeBenefitLaw?

Yes No

If“Yes,”pleaseattachdetails.


EmployedLawyersLiabilityCoverageSectionQuestionsPlease answer the following questions if Employed Lawyers Liability coverage is being requested

CurrentYear

PreviousYear

1. TotalnumberofEmployedLawyers(includingtemporaryandcontractattorneys)

2. DoanyofEmployedLawyersprovidelegalservicesinthefollowingpracticeareas:

a) EnvironmentalLawandCompliance?b) Copyright,Patent,Trademarkand/orotherintellectualpropertylaw?c) Litigation?d) SecuritiesLaw?


3. DoanyEmployedLawyersprovideMoonlightingLegalServices?

Yes No

4. Hasanypersonproposedforthiscoveragebeenthesubjectof,orbeeninvolvedin,

anyofthefollowingarisingoutofhisorherprovisionoflegalservices,irrespectiveofwhethersuchactivityaroseoutofworkperformedfortheApplicant:a) Anyreprimand,sanction,fineordisciplineby,orrefusedadmissionto,abar

association,court,administrativeorregulatoryagency?b) Anycivilorcriminallitigation,arbitration,claimoradministrativeorregulatory

proceedingduringthepastfiveyears?

Yes No

Yes No

If“Yes”toanyquestionabove,pleaseprovidedetails.

5. DescribethetypeofworktypicallyreferredbytheApplicanttooutsidecounsel


CrimeCoverageSectionQuestionsPlease answer the following questions if Crime coverage is being requested

CurrentYear PreviousYear1. Totalnumberemployees

a)USb)Foreign

a)b)

a)b)

2. NumberofUSlocationsa) Retailb) Non-retail

a)b)

a)b)

3. NumberofForeignlocationsa) Retailb) Non-retail

a)b)

a)b)

4. BankAccountsa) Areallbankaccountsreconciledmonthly?b) Arebankaccountsreconciledbysomeonenotauthorizedtowithdraw?c) Iscountersignatureofallchecksrequired?d) Isthecashexposureatanysinglelocationinexcessofrequesteddeductible?

Yes No Yes No

Yes No Yes No

5.AuditProceduresa)DoestheApplicanthavean:InternalAuditDepartment?CorporateSecurityDepartment?ITAudit/NetworkSecurityDepartment?

b) Howoftenarealldomesticlocationsaudited?c) Howoftenareallforeignlocationsaudited?d) Doyouprovidefraudawarenesstrainingforallyourstaff?e) Werethereanymaterialissuesininternalcontrolsidentifiedduringanyofthe

Applicant’sinternalorexternalauditsinthepastthreeyears?Ifyes,pleaseexplainactionstakentoaddressthoseissues.

Yes No Yes No Yes No

Yes No

Yes No

6.Computer/FundsTransferControlsa)Whatisthemaximumdollarvalueofwiretransfersperlocation?b)Doallwiretransfersrequireatleastdualapproval?c)Doallnon-repetitivewiretransfersrequireapprovedpurchaseordersandother

supportingdocumentation?d)HowoftendoestheApplicantrequirecomputeraccesscodesandpasswordsbe

changed?e)HaveanyvendorsorotherthirdpartiesbeengivenaccesstotheApplicant’s

computersysteminthepastthreeyears?f)(i)HastheApplicant’scomputersystems/ITdepartmentbeenauditedbyathirdparty

inthepastyear?(ii)Ifyes,werethereanyissuesbroughtupthatrequiredimmediateattention?

Iff)(ii)is“Yes,”pleaseprovidedetailsofactionstakentoaddressthoseissues.

________________

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


g)Doestheapplicantprovideanytypeof“SocialEngineeringFraud”trainingtotheir

employees?h)HowdoestheapplicantverifytheauthenticityandaccuracyofallFundsTransfer

requests?__________________________________________________________________________________________________________________________________________

Yes No

7. VendorControlsa) DoestheApplicantmaintainalistofallapprovedvendorsonaglobalbasis?b) DoestheApplicantperformbackgroundchecksonitsvendors?c) ArethereanyvendorsoftheApplicantthatwerenotsubjecttoabackgroundcheck?d) Doallpurchaseordersrequiredualapproval?e) HowdoestheApplicantverifytheauthenticityandaccuracyofanychangesmadeto

avendorsaccountconcerningbankaccountinformation,contactinformation,phoneinformation?__________________________________________________________________________________________________________________________


8. Clients’Property(completeifrequestingcoverage)a) WhattypeofworkwilltheApplicantbedoingforitsclients?

___________________________________________________________________b) Willthisworkbeprovidedontheclients’premises?c) WilltheApplicant’semployeeshaveaccesstomoney,securitiesortangibleproperty

ofitsclients?d) WhatcontrolsareinplacetoprotecttheApplicant’sclientsfromemployeetheft?

___________________________________________________________________

___________________________________________________________________

Yes No

Yes No


FRAUDWARNING

DCONLY:ITISACRIMETOPROVIDEFALSEORMISLEADINGINFORMATIONTOANINSURERFORTHEPURPOSEOFDEFRAUDINGTHEINSURERORANYOTHERPERSON.PENALTIESINCLUDEIMPRISONMENTAND/ORFINES.INADDITION,ANINSURERMAYDENYINSURANCEBENEFITS,IFFALSEINFORMATIONMATERIALLYRELATEDTOACLAIMWASPROVIDEDBYTHEAPPLICANT.FLONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTOINJURE,DEFRAUD,ORDECEIVEANYINSURERFILESASTATEMENTOFCLAIMORANAPPLICATIONCONTAININGANYFALSE,INCOMPLETE,ORMISLEADINGINFORMATIONISGUILTYOFAFELONYOFTHETHIRDDEGREE.LAONLY:ANYPERSONWHOKNOWINGLYPRESENTSAFALSEORFRAUDULENTCLAIMFORPAYMENTOFALOSSORBENEFITORKNOWINGLYPRESENTSFALSEINFORMATIONINANAPPLICATIONFORINSURANCEISGUILTYOFACRIMEANDMAYSUBJECTTOFINESANDCONFINEMENTINPRISON.MDONLY:ANYPERSONWHOKNOWINGLYORWILLFULLYPRESENTSAFALSEORFRAUDULENTCLAIMFORPAYMENTOFALOSSORBENEFITORWHOKNOWINGLYORWILLFULLYPRESENTSFALSEINFORMATIONINANAPPLICATIONFORINSURANCEISGUILTYOFACRIMEANDMAYBESUBJECTTOFINESANDCONFINEMENTINPRISON.NJONLY:ANYPERSONWHOINCLUDESANYFALSEORMISLEADINGINFORMATIONONANAPPLICATIONFORANINSURANCEPOLICYISSUBJECTTOCRIMINALANDCIVILPENALTIES.NYONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTODEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFORTHEPURPOSEOFMISLEADING,INFORMATIONCONCERNINGANYFACTMATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIME,ANDSHALLALSOBESUBJECTTOACIVILPENALTYNOTTOEXCEEDFIVETHOUSANDDOLLARSANDTHESTATEDVALUEOFTHECLAIMFOREACHSUCHVIOLATION.PAONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTODEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATIONORCONCEALSFORTHEPURPOSEOFMISLEADING,INFORMATIONCONCERNINGANYFACTMATERIALTHERETOCOMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIMEANDSUBJECTSSUCHPERSONTOCRIMINALANDCIVILPENALTIES.OKONLY:ANYPERSONWHOKNOWINGLY,ANDWITHINTENTTOINJURE,DEFRAUDORDECEIVEANYINSURER,MAKESANYCLAIMFORTHEPROCEEDSOFANINSURANCEPOLICYCONTAININGANYFALSE,INCOMPLETEORMISLEADINGINFORMATIONISGUILTYOFAFELONY.ORONLY:ANYPERSONWHOMAKESANINTENTIONALMISSTATEMENTTHATISMATERIALTOTHERISKMAYBEFOUNDGUILTYOFINSURANCEFRAUDBYACOURTOFLAW.ALLOTHERSTATES:ANYPERSONWHOKNOWINGLYANDWITHINTENTTOINJURE,DEFRAUD,ORDECEIVEANYINSURANCECOMPANYORANOTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFORTHEPURPOSEOFMISLEADINGINFORMATIONCONCERNINGANYFACTMATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIMEANDSUBJECTSTHEPERSONTOCRIMINALANDCIVILPENALTIES.INCO,ME,TN,VA,ANDWA,INSURANCEBENEFITSMAYALSOBEDENIED.


ThisquestionisapplicabletotheDirectorsandOfficersCoverageSectionifnocoverageiscurrentlymaintained.Doesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes NoThisquestionisapplicabletotheEmploymentPracticesCoverageSectionifnocoverageiscurrentlymaintained.Doesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No

ThisquestionisapplicabletotheFiduciaryLiabilityCoverageSectionifnocoverageiscurrentlymaintainedDoesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,fact,circumstanceorviolationofERISAoremployeebenefitlawwhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No

ThisquestionisapplicabletotheEmployedLawyersCoverageSectionifnocoverageiscurrentlymaintainedDoesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No

If“Yes”toanyquestionabove,pleaseprovidedetails.

ITISAGREEDTHATIFSUCHKNOWLEDGEORINFORMATIONEXISTS,ANYCLAIMARISINGTHEREFROM(WHETHERORNOTDISCLOSEDHEREIN),ISEXCLUDEDFROMTHEPROPOSEDCOVERAGE.SUCHEXCLUSIONWILLNOTOPERATEASAWAIVEROFANYOTHERREMEDIESTHEINSURERMAYHAVE.ITISFURTHERAGREEDTHATTHISSTATEMENTMADETHEREONSHALLBEDEEMEDANEXPRESSWARRANTYFORALLINSUREDSWHICHHASBEENRELIEDUPONBYTHEINSURERPURSUANTTOTHEISSUANCEOFCOVERAGE.

THEUNDERSIGNEDISANAUTHORIZEDREPRESENTATIVEOFTHEAPPLICANT,ANDHEREBYCERTIFIESTHATTHEYHAVEMADEREASONABLEINQUIRIESTOOBTAINANDPROVIDETHEANSWERS,INFORMATIONANDDOCUMENTATIONTHATISRESPONSIVETOTHEQUESTIONSANDREQUESTSCONTAINEDINTHISAPPLICATION,ANDREPRESENTSTHATTHEANSWERS,INFORMATIONANDDOCUMENTATIONISTRUE,ACCURATEANDCOMPLETETOTHEBESTOFTHEIRKNOWLEDGEANDBELIEF.__________________________________________________________________________SignatureofChiefExecutiveOfficer,ChiefFinancialOfficer,orPresidentoftheApplicant__________________________________________________________________________PrintName/Title___________________________Date

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