By Mail
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By Overnight Carrier
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Broadridge Corporate Issuer Solutions, LLC
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Broadridge Corporate Issuer Solutions, LLC
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Attention: BCIS Re-Organization Dept.
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Attention: BCIS IWS
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P.O. Box 1317
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51 Mercedes Way
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Brentwood, New York 11717-0693
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Edgewood, New York 11717
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No. of whole shares subscribed for pursuant to exercise of Basic Subscription Right:
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Plus
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No. of additional shares subscribed for pursuant to exercise of Over-Subscription Right:
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TOTAL SHARES SUBSCRIBED:
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times Subscription Price per whole share
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TOTAL PAYMENT DUE:
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is being delivered to the Subscription Agent herewith; or
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has been delivered separately to the Subscription Agent, and is or was delivered in the manner set forth below (check appropriate box and complete information relating thereto):
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certified bank or cashier’s check drawn upon a U.S. bank payable to “Broadridge Corporate Issuer Solutions, LLC”; or
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wire transfer of immediately available funds
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Name of maker:
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Date of check, draft or money order:
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Bank on which check is drawn or issuer of money order:
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Check, wire reference or identifying number:
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Signature(s):
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Name(s):
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Address:
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Telephone:
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(please print or type)
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Account No.(s):
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Dated:
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(Address)
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(Name of Firm)
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(Area Code and Telephone Number)
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(Authorized Signature)
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