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JaLIJ REQUIREMENT't: ~.~~..:~:~.~.:~'~~'.':::..,: :~. :~~'~.: ~:~:::.>~:~~:'.: tiP#$ .. 3ai}A'~AVSt :~ JAILY .1'1.71 t1 .:/L <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I OERTI FV UNDER PENALTY OF LAW THAT I NAVE PERSONALLY E%AMINED MID TELEPHONE DATE <br /> AM FA MILIM WITH THE INFO RMATION SUBMITTED HEREIN; MID BASED ON <br /> MY INQUIRY OF THOSE IN DIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> <br />JQFiN M WALTFHS '- <br />' OBTAINING THE INfORMATION <br />TRUE, ACOURATE AND COM <br />N <br />FICANT PEN <br />TIES FOR , 1 BEDEVE THE SUBMITTED INFORMATION IS <br />PLETE. I AM AWARE THAT THERE ME <br />SUBMlTTNG FMSE INFORMATION <br />INOLUDING <br />MANAGER OF MI1JE SE RVICFS SIG <br />I <br />AL <br />THE POSSIBILITY OF RNE AND I , <br />MPRISONMENT. SEE 18 U.S.C. 1 1001 AND 33 <br />610NATURE OF PRINCIPAL EXECUTNE 970 Q~ - ~~8 9 7 1O a'8 <br />TYPED OR PRINTED ~ u.s.c. f t Ste. Iflntuti++ Inter IrwAr mlNh+nrY Lm/.d+ Fxw+ up ro S IO.ODO <br />nwwmuxtl+n inP<ismwne olarwwn sntF+trn.nw6rw+l OFFICER OR AUTHORIZED AOENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Rs/erence all attachments here! ~ - <br />T;; ~; TL,fAI In.,~t Llf;l' - '•:lll :-` <br />~ ~A[V1_D. C `; i_1TLcA;;Lr. S;iLii. S L[ i[T; A~FL[r-~ (I:r. I~Y~.,24ri•( '~:Ci~' ~J<<:T <br />S.I;LIuS Li <br />i5:.. i.<~I~+ !; :;I Ti~~:tJL•_ t'[TS ><d[v1.U Flak 1JYR,c4~!k ~.:!_.CIY Ev~+uf-ATfaGH J-:CUrE,hf~7IJ:-)c~ [.n,;, <br />~'1 I <br />l n <br />, -t, ~I ~T't t '~ ~ c <br />• <br />- 51 ievloue editions may be used. <br />E orm 3320- 10 RE LACES EP F R T 0 W C PAGE <br />MA NOT B USED.) (J ~ J 1 L / 1 ^ O 4 .: 4 ~ J ~ 3 L 10F <br />