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If delivering by mail:
American Stock Transfer & Trust Company, LLC Operations Center Attn: Reorganization Department P.O. Box 2042 New York, New York 10272-2042 |
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If delivering by courier:
American Stock Transfer & Trust Company, LLC Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
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| | Certificate Nos. (if available) (indicate priority if not all shares are purchased): |
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| | Name(s) of Record Holder(s): | | |
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Dated: , 2016
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| | If shares will be tendered by book-entry transfer, provide the following information: |
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| | Name of Tendering Institution: | | |
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| | Account Number of Book Entry Transfer Facility: | | |
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| | Name of Firm: | | |
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| | Authorized Signature: | | |
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| | Name: | | |
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Dated: , 2016
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