“Annex I”

( SRC Rule 52.1-6)

CUSTOMER ACCOUNT INFORMATION FORM

Account Type: Cash ( ); Discretionary ( ); Institutional ( )

Margin ( )

Name __________________________________ TIN # ______________________________________

Name of Spouse: ______________________________________________________________________

Address _______________________________________________________________________________

Home Tel.# _______________________________ Bus. Tel.# ___________________________________

Bus. FAX # _________________________ Occupation ____________________________________

Is Customer of Legal age? YES ( ) NO ( )

Employer ______________________________________

Is the Employer a Broker Dealer? YES ( ) NO ( )

Address _______________________________________________________________________________

Nationality ________________ Name of Attorney-in-fact, if applicable ______________________

Officer or Director of an Exchange-listed company? YES ( ) NO ( )

If yes, identify the company ____________________________________________________________

Officer, Director or Shareholder or a Broker Dealer?

If yes, identify the Broker Dealers and describe relationship________________________________

How long known by Salesman introducing Account ? ____________________________________

Customer was referred by: ______________________________________________________________

Customer’s Bank: ______________________________________________________________________

Investment Objective: Speculation ( ) Preservation of Capital ( )

Growth ( ) Long-term investment ( )

Annual Income: ______________;Assets: ______________; Net worth: _________________________

Are duplicate confirmations required? YES ( ) NO ( )

Identify to whom to be sent and relationship to customer:_______________________________

Accounts with Other Broker Dealers: ____________________________________________________

Annex I – SRC Rule 52.1-6

January 2001
________________________________________ __________________
Signature of Customer or Attorney-in-fact Date

______________________________________________ __________________
Signature of Person authorized to exercise Date
discretion in account.

________________________________________________ __________________
Signature of Salesman introducing the Account Date

_______________________________________________ __________________
Signature of partner, officer or manager Date
accepting the account.

Annex I – SRC Rule 52.1-6

January 2001