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* )as! / Digi!s o0 '1asis N.mber RE&'IRE$ SI(!"%'RE

& 1a2e read and .nders!ood !1e Fine Prin! s!a!ed belo3 and 1ereb "er!i0 !1a! !1e in0orma!ion gi2en on !1is 0orm is !r.e and "orre"!( * $igna!.re : * Da!e :

%he Fi)e Pri)t * Rules +y ROS De!ails s.bmi!!ed 3ill be .sed solel 0or "l.b 4.r4oses( Pri2a!e de!ails 3ill be deemed as "on0iden!ial and a""ess !o !1e in0orma!ion is !o a.!1ori5ed "l.b members onl ( T1e "l.b s1all no! be 1eld liable agains! an and all liabili!ies and !1e member 3ill indemni0 !1e "l.b6 i!s members and asso"ia!es 0rom and agains! an and all liabili!ies d.ring an e2en! organi5ed b !1e 'l.b( All a"!i2i!ies 4ar!i"i4a!ed b an member d.ring an e2en! is done so b !1e 0ree 3ill o0 ea"1 member(

For 'l.b 7se onl Recei,ed +y $ate Recei,ed Mem+ership !um+er * * * P%E+,'