! "#$%&'!(#)%*+!,+-'./0+&/! !"!#$%&'()($!'%&!')*$!
! 111!2#./3!"%/.45!6$+&4+! &+'$%+,%!-.*/*$%0%
! "#$%&'7!"6!!89:;<! +&&1*2+#$%34!5$*(##+*'!%
! =>;>?!<@1ABB8B7!CD/E!B>; <! %
! 3//-FGGHHHE*#$%&'*'EI#$G*%/JAK+-'./0+&/5G-#)%*+!
!
!
!
CLC2M!(NOPOMCN!(CNPQMF!(6NM!6!R!CSTQUQM!>!R!6((VQ"62M!WXCYMQO226QNC!
(6ZC!9!O[!;!
!"!#$%&'()($!'%&!')*$%+&&1*2+$*(#,%&+'$%+,%!-.*/*$%0%
+&&1*2+#$%34!5$*(##+*'!!
=Please&type&or&print&clearly.?!
!
M3+! \#))#H%&I! ]4+5/%#&5! 045/! ^+! '&5H+.+K! ^J! '))! &'/4.')! -+.5#&5! \#.! H3#0! %&\#.0'/%#&! H'5!
-.#$%K+K! %&! ('./! 6! =%&*)4K%&I! CD3%^%/5! 97! ;7! <7! 17! '&KG#.! B?! R! %&*)4K%&I! +'*3! #\\%*+.7! K%.+*/#.7!
0'&'I+.7! 0+0^+.7! I+&+.')! -'./&+.7! -'./&+.7! #.! #/3+.! -+.5#&! 3#)K%&I! 9_`! 0#.+! #H&+.53%-!
%&/+.+5/E!
!
Q\!J#4! '&5H+.!ab+5c!/#!'&J!#\!/3+!]4+5/%#&57!-)+'5+!'//'*3! '!5+-'.'/+!53++/!#\!-'-+.!+D-)'%&%&I!J#4.!
'&5H+.! '&K! -.#$%K%&I! '))! %&\#.0'/%#&! &+*+55'.J! \#.! /3+! (#)%*+! ,+-'./0+&/! /#! *#&\%.0! /3+!
%&\#.0'/%#&! -.#$%K+K7! %&*)4K%&I7! ^4/! &#/! )%0%/+K! /#! /3+! d4.%5K%*/%#&! H3+.+! /3+! '*/%$%/J! #**4..+K7!
.+)+$'&/! K'/+5! %&$#)$+K7! '&K! *#-%+5! #\! .+)+$'&/! K#*40+&/5E!!6!ab+5c!'&5H+.!K#+5!&#/!&+*+55'.%)J!
0+'&! J#4! H%))! ^+! K+&%+K! '! -+.0%/E! ! 6KK%/%#&')! K#*40+&/'/%#&! 0'J! ^+! .+]4+5/+K! ^J! /3+! (#)%*+!
,+-'./0+&/!%\!/3+!%&\#.0'/%#&!-.+5+&/+K!%5!K++0+K!%&54\\%*%+&/!/#!*#0-)+/+!/3+!%&$+5/%I'/%#&E!
!
6!5+-'.'/+!]4+5/%#&&'%.+!045/!^+!*#0-)+/+K!\#.!+'*3!&'/4.')!-+.5#&E!
!
.6<8%PJM%8<8:%6KKE;8C%HJ:%J:%: 8?8; <8C%6%E;?8@>8R%?8:D;H;?6D8R%K8:7;DR%J:%
:8F;>D:6D;J@%DJ%K:6?D;?8%;@%6%:8FME6D8C%K:JH8>>;J@%M@C8:%6@P%@678%JDL8:%
DL6@%DL8%@678%E;>D8C%J@%DL;>%6KKE;?6D;J@Q%
%
.6<8%PJM%8<8:%L6C%6%E;?8@>8R%?8:D;H;?6D8R%K8:7;DR%J:%:8F;>D:6D;J@%DJ%
K:6?D;?8%;@%6%:8FME6D8C%K:JH8>>;J@%C8@;8CR%>M>K8@C8CR%:8<JS8CR%J:%;@%6@P%
T6P%?J@C;D;J@8CR%E;7;D8CR%J:%:8>D:;?D8C%;@%J:%NP%6@P%E;?8@>;@F%J:%JDL8:%
:8FME6DJ:P%6F8@?PQ%
%