Form 3-Q - Report Of Sale Of Securities Page 3

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Issuer or
Dealer
(Full Name)
B
y
(Signature)
(Date)
(Name)
(Official Capacity)
The Division suggests Form 3-Q be sent certified mail for verification of receipt, or send a copy of this form together
with a self-addressed, stamped envelope.
Com 4596 (Rev. 3/16)
EOE/ADA SERVICE PROVIDER
FOR TTY USERS DIAL ORS 1-800-750-0750

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