144 Restricted Stock Forms Template, Form 144 - Notice Of Proposed Sale Of Securities Page 2
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3UNITED STATES
OMB APPROVAL
SECURITIES AND EXCHANGE COMMISSION
OMB Number:
3235-0101
Washington, D.C. 20549
Expires:
December 31, 2006
Estimated average burden
hours per response ........... 4.47
FORM 144
SEC USE ONLY
DOCUMENT SEQUENCE NO.
NOTICE OF PROPOSED SALE OF SECURITIES
PURSUANT TO RULE 144 UNDER THE SECURITIES ACT OF 1933
CUSIP NUMBER
ATTENTION:
Transmit for filing 3 copies of this form concurrently with either placing an order with a broker to execute sale
or executing a sale directly with a market maker.
WORK LOCATION
1 (a) NAME OF ISSUER (Please type or print)
(b) IRS IDENT. NO.
(c) S.E.C. FILE NO.
1 (d) ADDRESS OF ISSUER
STREET
CITY
STATE
ZIP CODE
(e) TELEPHONE NO.
AREA CODE
NUMBER
2 (a) NAME OF PERSON FOR WHOSE ACCOUNT THE SECURITIES (b) IRS IDENT. NO.
(c) RELATIONSHIP TO
(d) ADDRESS STREET
CITY
STATE
ZIP CODE
ARE TO BE SOLD
ISSUER
INSTRUCTION:
The person filing this notice should contact the issuer to obtain the I.R.S. Identification Number and the S.E.C. File Number.
SEC USE ONLY
3 (a)
(b)
(c)
(d)
(e)
(f)
(g)
Title of the
Number of Shares
Aggregate
Number of Shares
Approximate
Name of Each
Class of
Name and Address of Each Broker Through Whom the
Broker-Dealer
or Other Units
Market
or Other Units
Date of Sale
Securities
Securities
Securities are to be Offered or Each Market Maker
File Number
To Be Sold
Value
Outstanding
Exchange
(See instr. 3(f))
To Be Sold
who is Acquiring the Securities
(See instr. 3(c))
(See instr. 3(d))
(See instr. 3(e))
(MO. DAY YR.)
(See instr. 3(g))
INSTRUCTIONS:
3. (a) Title of the class of securities to be sold
1. (a) Name of issuer
(b) Name and address of each broker through whom the securities are intended to be sold
(b) Issuer’s I.R.S. Identification Number
(c) Number of shares or other units to be sold (if debt securities, give the aggregate face amount)
(c) Issuer’s S.E.C. file number, if any
(d) Aggregate market value of the securities to be sold as of a specified date within 10 days prior to the filing of this notice
(d) Issuer’s address, including zip code
(e) Number of shares or other units of the class outstanding, or if debt securities the face amount thereof outstanding, as shown
(e) Issuer’s telephone number, including area code
by the most recent report or statement published by the issuer
(f) Approximate date on which the securities are to be sold
2. (a) Name of person for whose account the securities are to be sold
(g) Name of each securities exchange, if any, on which the securities are intended to be sold
(b) Such person’s I.R.S. identification number, if such person is an entity
(c) Such person’s relationship to the issuer (e.g., officer, director, 10%
stockholder, or member of immediate family of any of the foregoing)
(d) Such person’s address, including zip code
Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB control number.
SEC 1147 (01-04)
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