Securities Questionnaire First Name Last Name Are you Representing a Corporation, Trust, Partnership or Other Entity? Are you Representing a Corporation, Trust, Partnership or Other Entity? Yes No Please Provide the Name of the Entity Please Indicate Your Position Street Address City State Zip/Postal Code Country Phone Number Email Address Company Name or Ticker Symbol Are you a current or former employee of the company? Are you a current or former employee of the company? Yes No Please identify your transactions in the relevant security/securities: Number of Purchases 01234Upload Document Purchase 1 Purchases Purchases *Common StockPreferred StockBondsCallsPuts Purchase Date Price Per Share Number of Shares Purchase 2 Purchase Date Purchases Purchases *Common StockPreferred StockBondsCallsPuts Number of Shares Price Per Share Purchase 3 Purchases Purchases *Common StockPreferred StockBondsCallsPuts Purchase Date Number of Shares Price Per Share Purchase 4 Purchases Purchases *Common StockPreferred StockBondsCallsPuts Purchase Date Number of Shares Price Per Share New Field Number of Sales 01234Upload Document Sale 1 Sales Sales *Common StockPreferred StockBondsCallsPuts Sale Date Number of Shares Price Per Share Sale 2 Sales Sales *Common StockPreferred StockBondsCallsPuts Sale Date Number of Shares Price Per Share Sale 3 Sales Sales *Common StockPreferred StockBondsCallsPuts Sale Date Number of Shares Price Per Share Sale 3 Sales Sales *Common StockPreferred StockBondsCallsPuts Sale Date Number of Shares Price Per Share New Field New Field Plaintiff's service as a representative party on behalf of a class during the last three years. Plaintiff's service as a representative party on behalf of a class during the last three years. Plaintiff has neither served nor sought to serve as a representative party on behalf of a class under the federal securities laws during the last three years, except if detailed below. Message Attorney-client Relationship Attorney-client Relationship *I understand that an attorney-client relationship is not created by submitting this information to Kehoe Law Firm, P.C. Submit
