Director and Officer Proxy statement Questionnaire

All the company’s directors and officers are being asked to respond to this questionnaire. It is intended to help determine your independence and any related party disclosures required in accordance with the rules of the Securities and Exchange Commission and any related stock exchanges regulations. Please complete this questionnaire for full and adequate disclosure. If a specific question is not applicable, please indicate ‘Not Applicable’ or ‘NA’. If you require additional space for answering a question, attach extra sheets. Please do not leave any questions unanswered. Please complete, sign, date and return one copy of this questionnaire to the office of the Chief securities Counsel and SEC reporting Controller.

1. Please provide the following personal information:[SEC reg S-K, items 401(a) and (b)]Name: _______________________________________Address: _____________________________________

____________________________________________________________________________________

Date of Birth: ____ / ____ / ____ [SEC reg S-K, item 401(d) 2. Do you have a family member or relative who is also a director or officer of this company?

___ Yes ___ No [SEC reg S-K, items 401(a), (b),(c)]If Yes, please disclose this relationship: _________________________________________________________________________________________________________________________________________________________________________________________________________3. Describe your present occupation and position:Job Title / Retired: ____________________________________________________Employer Name: ______________________________________________________Principal Business: ____________________________________________________Number of Years in this Position: ________4. List prior occupations and positions (during last ten years)Start Date Stop Date Title Employer

___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________ ___/___ ___ /___ ______________________ ________________________

5. Describe your proposed position and responsibilities within the company:Title: _____________________________________Primary Responsibility: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. If you are a director or a person chosen or nominated to become a director. Please disclose

the name of ‘other public corporations’ of which you are currently serving as an Officer or Director:

__________________________________________________________________________________________________________________________________________

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_____________________________________________________________________

7. List any and all forms and amounts of compensation you have or will receive as an Officer or Director with our company: [SEC reg S-K, items 402g and 404(a), SEC rule 16b-3(b)(3), IRS Reg. 1.162-27(c)(3)]

Type of compensation (fees, salary, bonus, property, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________Frequency of compensation: ______________________________________________________________________________________________________________________________________________________________________Benefits: (use of company property, club memberships, aircraft, etc.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Will or have you or any family member or relative used company property and assets for personal use? ____ Yes ____ No [SEC reg S-K, item 404(a)]

If yes, please describe use: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If yes, did you or your family member or relative reimburse the company?____ Yes ____ No9. Will the company provide you or any family member or relative with special services, such

as tax return preparation, personal financial planning, legal services, or other services for your own personal use? ____ Yes ____ No

If yes, please describe: ________________________________________________________________________________________________________________________________________________________________________________10. Will or have you or any family member or relative received benefits from suppliers,

customers, or other parties which does business with the company? ___Yes ___NoIf yes, please describe benefits (free golf memberships, special discounts, reduced rates, gifts, and other forms of compensation) and source: ____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________11. Are you actively working as a “promoter” of the company; i.e. you are directly or indirectly

behind creating and organizing the company ____ Yes ____ NoIf yes, did you receive any form of compensation as a promoter? ___ Yes ___ NoWhat was the form of this compensation? ____________________________________________________________________________________________________________________________________________________________________12. Please fully disclose your current equity ownership in the company. This would include the

total number of shares you own, date acquired, the amount you paid, if the ownership allows voting rights, and if the ownership allows you to sell the shares. Also disclose if family

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members or relatives have an equity interest in the company. [SEC reg. S-K, items 402, 403(b), SEC rule 13d-3, 16a-2, 16a-3]

Number of Shares Date AmountOwned Acq Paid Voting Power Able to Sell Your Ownership:_______ ________ ___________ Yes No Yes NoSpouse:_______ ________ ___________ Yes No Yes NoFamily Member(s):_______ ________ ___________ Yes No Yes NoRelatives:_______ ________ ___________ Yes No Yes NoTrust:_______ ________ ___________ Yes No Yes NoOwned by Company, Partnership or other entity where you are an Officer/Director:_______ ________ ___________ Yes No Yes No

Beneficial owner table

Title of equity security

Number of shares or units

Nature of beneficial ownership

Explanations

Shares or Units included but issued in Another’s nameShares or Units Excluded but issued in Your nameTable of Rights

Common stock OtherNumber of shares or units as to which you have sole voting powerNumber of shares or units as to which you have shared voting powerNumber of shares or units as to which you have sole investment powerNumber of shares or units as to which you have shared investment powerNumber of shares or units as to which you have the ‘right to acquire’ beneficial ownership

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13. Please fully disclose any options, rights, or other bonus type arrangements you own with the company:

Date Amount ExerciseType of Arrangement Acquired Duration Paid Price _________________ ________ ________ ________ __________________________ ________ ________ ________ _________

14. Has the company adjusted the exercise price of or otherwise repriced any of your options during the last fiscal year? ____Yes ____No

15. Did you have any transactions, exempt from Form 4 filing, which now need to be reported on Form 5?___Yes____No

16. Do you plan on having any type of arrangement or agreement with any person or entity that has or will have an equity ownership interest in the company with respect to first offer, pledge, or other transfer of stock of the company? [SEC reg S-K, item 403(a)]

____ Yes ____ NoIf yes, please describe this arrangement or agreement; disclose the parties involved and number of shares affected: ________________________________________ __________________________________________________________________________________________________________________________________ _________________________________________________________________

17. Are you aware of any arrangement or possible change in the control of the company, including a pledge of securities? ____ Yes ____ No [Rule 10b5-1]

If yes, please describe the persons involved and the nature of the change: ______________________________________________________________________________________________________________________________________________________________________________________________________

18. In the last five years, please indicate if you have filed or anyone has filed against you a petition under the Bankruptcy Act or any insolvency laws of any state or country.

____ Yes ____ No [SEC Reg. S-K, items 103, 401(f) and 401(g)]19. In the last ten years, please indicate if you have been convicted in any criminal proceeding,

excluding traffic violations and misdemeanors. ____ Yes ____ No

If yes, indicate the nature of the conviction, name of court, date of conviction, and the penalty or disposition of the case:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

20. In the last ten years, indicate if you were subject of a court order, judgement, or decree of any court, the SEC, CFTC, NYSE, American Stock Exchange or NASD which enjoined or otherwise limited your capacity for acting as an investment advisor, underwriter, broker, dealer, or affiliated person, director, officer, or employee of any investment company, bank, insurance company, or any activity connected to the purchase or sale of securities under federal and state securities laws or commodities laws?

_____ Yes ____ NoIf yes, indicate the nature of the restriction, date imposed, and the penalty or disposition of the restriction:

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____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________21. Complete the following information if you or any business associate of yours is or has been

indebted to the Company and any of its subsidiaries at anytime since formation of the Company:

Name of Borrower: ______________________________________Maximum Amount of Debt: _______________________________Amount Currently Outstanding: ____________________________Annual Interest Rate: _________Terms, Conditions, and Description of Loan: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________22. Indicate if you or any business associate is party to a pending lawsuit or legal proceeding

involving the Company or the assets of the Company and any of its subsidiaries?_____ Yes _____ NoIf yes, describe the lawsuit or legal proceeding, the name of the court, the amount claimed, the parties involved, and date(s) of such proceedings:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________23. To the best of your knowledge, are you aware of any material legal proceeding not before

mentioned in question #20 which could have a substantial effect on the financial condition of the Company?

_____ Yes _____ NoIf yes, describe the pending legal proceeding, the name of the court, the amount claimed, the parties involved, and date(s) of such proceedings:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

24. Describe any interest you have or any of your business associate has in any legal proceeding which could be adverse to the Company?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

25. To the best of your knowledge, are you aware of any agreement, trust, or other arrangement which holds more than 5% of the Company? [SEC reg , item 402(h) and 403(c)]

____ Yes ____ NoIf yes, indicate the amount held and the duration of the agreement:___________________________________________________________________

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_________________________________________________________________________________________________________________________________________________________________________________________________________26. To the best of your knowledge, are you aware of any director, officer, or partner who is

insured or indemnified against liability in his or her capacity as a director, officer, or partner? [SEC reg S-K, item 702]

_____ Yes _____ NoIf yes, identify the name(s), position(s), and extent of indemnification if known?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

27. Do you have any relationship with an investment banker, broker, underwriter or other securities dealer which is more than the usual maintenance of an open account?

_____ Yes _____ NoIf yes, describe this relationship(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

28. Do you have any material interest, association, affiliation, or relationship with the Underwriter or Legal staff for the Company?

____ Yes ____ NoIf yes, describe the relationship: ____________________________________________________________________________________________________________________________________________________________________________________29. Are you aware of any arrangement or agreement which is designed to: a) limit or restrict the

sale of interest in the Company; b) stabilize the marketplace for the stock of the Company being registered; c) hold underwriters and/or dealers responsible for their participation; or d) change control of the Company?

_____ Yes _____ NoIf yes, describe the details of the arrangements: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

30. Identify the sale of unregistered securities by you or any person, firm or company where you have a controlling interest or you serve as director, officer or partner for the last three years:

Name of Issuer: ___________________________________Date of Sale: _____________________________________Type of Security: _________________________________Name of Purchaser: _______________________________Purchase Price: ___________________________________Total Amount of Transaction: _______________________Relationship of Purchaser: __________________________ Residence of Purchaser: ____________________________

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Occupation of Purchaser: ___________________________NOTE: Attach documentation regarding the sale(s)31. Have you ever been indemnified by the Company as a result of serving as an officer,

director, partner, agent, or employee of the Company?_____ Yes _____ NoIf yes, describe the indemnification: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________32. Have you ever been disqualified, censored, or reprimanded by a professional organization or

association while practicing as a professional (such as lawyer, doctor, realtor, CPA, etc.)?____ Yes ____ NoIf yes, describe the actions taken and the current disposition:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

33. Are you to be elected pursuant to any arrangements or understanding between yourself and any other party?____Yes ____No

34. If yes, please list all the names of such persons or entities and describe the arrangements___________________________________________________________________________________________________________________________________________________________________________________________________________________________

35. [SEC reg S-K, item 402j and Schedule 14A, item 7] The company’s records indicate that of the ___ board meetings held during the last fiscal year, you attended __ of suck meetings, and that of the ___ meetings of the __________ committee(s) on which you serve, you attended ___ such meetings. Is this correct?___ Yes ___NoIf no, please provide correct information

36. If you have been nominated to stand for election to the Board of Directors of the Company at the 2015 Annual Meeting of Stockholders, do you agree to serve if elected?___Yes ____No

37. Did you, your affiliates or member of your immediate family receive last fiscal year any compensation for service rendered to the company or its subsidiaries?___Yes ___No

38. Did you, your affiliates or member of your immediate family receive last fiscal year benefits from third party due to any relationship with the company?____Yes ___No, if yes, describe the nature of these transactions ________________________________________________________________

39. Did you, your entity or member of immediate family receive any property or services from the affiliated group in exchange transaction?___Yes ___No

40. [IRS reg 1.162-27(c)(3)] Are you, or have you been during the last fiscal year, employed or self employed by an entity (including any sole proprietorship, trust, estate, partnership, corporation or other entity) that performed personal services for the Affiliated group?___Yes ___No

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41. Do you now own or have owned, during the company’s last fiscal year, of record or beneficially, in excess of a 10% equity interest, any firm, corporation, or other business or professional entity? ____Yes ___No

42. What is the present state of your physical health?________________________________________________________________________________________________________________________________________43. If you have consented to accept a position or role within the Company (such as director,

advisor, etc.), please describe your role:______________________________________________________________________________________________________________________________________________________________________________________________________

The information provided in this questionnaire is supplied for the purpose of disclosing certain information to potential investors. If there is any other information not previously covered in this questionnaire that you believe should be disclosed, then set forth all relevant information as an attached sheet. In the event that other developments or circumstances make the information disclosed in this questionnaire misleading, false, incomplete or otherwise inaccurate, notify the Company or its securities counsel legal staff and SEC reporting staff immediately by telephone at (___) ____________.

I AGREE TO THE INFORMATION SET FORTH IN THIS QUESTIONNAIRE AND I AGREE TO NOTIFY THE COMPANY IMMEDIATELY ON BECOMING AWARE OF ANY CHANGES IN THE FOREGOING INFORMATION AND WILL ENDEAVOR TO DO SO PRIOR TO MY, AND ANY OF MY AFFILIATES UNDER MY CONTROL DIRECTLY OR INDIRECTLY ENTERING INTO ANY RELATIONSHIP OR TRANSACTION THAT WOULD REQUIRE CHANGES IN MY ANSWERS TO ANY QUESTIONS. I AGREE TO CONTACT THE COMPANY BY TELEPHONE AT (____)_____________ IMMEDIATELY.I ALSO ACKNOWLEDGE THAT I HAVE REVIEWED THE COMPANY’S CODE OF ETHICS AND BUSINESS CONDUCT.

______________________________________(Signature of Director or Officer)

______________________________________(Print Name)

_____________________(Date)

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