Professional Community
Association Manager
®
(PCAM
®
)
Designation Application
Prerequisites
n Five years of direct community association management experience.
n Successfully passed the PMDP M-200 level programs (with the last finished course
having concluded within the past five years).
n Successfully passed the CMCA exam administered by CAMICB.
Application Instructions
n Complete the prerequisites.
n Fill in this application with Adobe Acrobat Reader or print clearly in ink. To work in Reader: save the file on your
computer’s desktop, complete the form, and save again using your last name in the filename (e.g., PCAM_Jones.pdf)
before printing. If additional pages are needed, please label clearly and attach to this application.
n Be honest, accurate and thorough in completing all sections of this application.
n Candidates must earn a minimum total of 125 points on this form, including:
— Formal education, Section I (maximum 30 points)
— Professional designations or licenses, Section I (maximum 20 points)
— CAI and industry-related education and service, Section II (minimum 55 points)
n Submit completed application with non-refundable application fee to the CAI headquarters office, 6402 Arlington
Blvd., Suite 500, Falls Church, VA 22042, fax to (240) 524-2424, or e-mail to payments@caionline.org.
Fees: $195 for individual manager members of CAI and $430 for non-members
n Please note: All applicants have one year from the date of application approval to complete the Case Study.
Failure to complete a Case Study will require candidates to re-apply with payment. Submit this application after
you have met the above qualification criteria before applying to sit for the case study.
CAI reserves the right to modify the PCAM fees and criteria as stated above.
MEMBERSHIP DESIG/LIC FORMAL EDU SECTION I SECTION II SECTION III TOTAL
COMMENTS:
For Official Use Only
4
/2018
PCAM APPLICATION | PAGE 2
Candidate Information
CAI MEMBER NUMBER
FIRST NAME AND MIDDLE INITIAL
LAST NAME AND SUFFIX
HOME ADDRESS
CITY STATE ZIP
CURRENT TITLE
FIRM/ASSOCIATION
BUSINESS ADDRESS
CITY STATE ZIP
PREFERRED E-MAIL ADDRESS
HOME PHONE MOBILE PHONE
BUSINESS PHONE
Payment Information
MEMBER $195 (INDIVIDUAL MANAGER MEMBERSHIP REQUIRED FOR MEMBER APPLICATION RATE) NON-MEMBER $430
CHECK ENCLOSED (PAYABLE TO CAI) VISA MASTERCARD AMEX DISCOVER
CARD NUMBER EXP. DATE
NAME ON CARD
BILLING ADDRESS
CITY STATE ZIP
SIGNATURE
General Information
If you are paying by credit card, please complete this form and then submit the application by e-mail with any
required attachments. If you are paying with a check, please complete this form on a computer, print and then sign.
Mail the printed and signed application with your payment to the address shown on page 1.
click to sign
signature
click to edit
PCAM APPLICATION | PAGE 3
Professional Designations or Licenses Maximum 20 points
Please indicate the date you received any of the following, as well as relevant certificate or license numbers.
DATE (MM/YY) CERTIFICATE OR LICENSE NUMBER POINT VALUE
AMS DESIGNATION 10
CMCA CERTIFICATION 10
OTHER DESIGNATION 10
REAL ESTATE BROKER’S LICENSE 10
STATE LICENSE 10
SALESPERSON’S LICENSE 10
Formal Education Maximum 30 points
Please indicate institution, date, and degree received. POINT VALUE
HIGH SCHOOL _________________________________________________________________________________ 0
CERTIFICATE PROGRAM _________________________________________________________________________________ 10
ASSOCIATE’S DEGREE _________________________________________________________________________________ 15
BACHELOR’S DEGREE _________________________________________________________________________________ 20
MASTER’S DEGREE _________________________________________________________________________________ 25
DOCTORATE OR EQUIVALENT _________________________________________________________________________________ 25
Professional Management Development Program Requirements
Please indicate the city, month and year each course was taken and attach program completion certificates or course
transcripts.
POINT VALUE
DATE (MM/YY) CITY
M-100 10
M-201 10
OR M-130 10
M-202 10
& M-203 10
OR M-120 10
M-204 10
OR M-110 10
M-205 10
& M-206 10
OR M-140 10
PCAM APPLICATION | PAGE 4
FROM DATE (MM/YY) TO DATE (MM/YY) OR PRESENT
COMPANY ______________________________________________________________________________________________________________
POSITION ______________________________________________________________________________________________________________
DESCRIPTION ______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
FROM DATE (MM/YY) TO DATE (MM/YY) OR PRESENT
COMPANY ______________________________________________________________________________________________________________
POSITION ______________________________________________________________________________________________________________
DESCRIPTION ______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
FROM DATE (MM/YY) TO DATE (MM/YY) OR PRESENT
COMPANY ______________________________________________________________________________________________________________
POSITION ______________________________________________________________________________________________________________
DESCRIPTION ______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
I. Work Experience Summary
THIS SECTION MUST detail the required five years of direct community association experience. Start with the
present year of your professional work experience. Include a complete and accurate description of your position and
services performed. All community association management positions should include the names and addresses of all
community associations involved. Attach additional sheets if necessary.
A community association manager will have the knowledge, ethics, professionalism and skills with verifiable
experience in financial, administrative, and facilities management in at least one community association, either
commercial or residential. The community association manager must be compensated for providing professional
guidance and assistance to the board of directors of any association(s) managed by that community association
manager, whether the individual is acting as an full time independent contractor, or as an employee of a
management firm, or as a general manager or executive director of a common interest development. Management
of property other than community associations will not meet the qualifications for community association manager.
PCAM APPLICATION | PAGE 5
CAI headquarters conference attendance POINT VALUE
DATE (MM/YY) LOCATION
10
10
CAI headquarters manager webinar(s) (minimum 3 hours’ duration)
DATE (MM/YY) TOPIC(S)
5
5
5
5
Attendance at other CAI headquarters educational programs (minimum one day duration)
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY) LOCATION
10
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY) LOCATION
10
Attendance at CAI chapter educational programs (minimum one day duration)
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY) SPONSOR
10
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY) SPONSOR
10
Attendance at CAI chapter educational programs (minimum 3 hours’ duration)
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY) SPONSOR
5
PROGRAM TITLE/TOPIC ______________________________________________________________________________________
DATE (MM/YY)
SPONSOR
5
Attendance at CAI chapter educational breakfasts, luncheons and/or dinner events
DATE (MM/YY) CHAPTER
5
5
5
CONTINUED ON NEXT PAGE
II. CAI and Industry-Related Education Programs
55 POINTS are required in this section. Please include all relevant details and attach additional sheets if necessary.
PCAM APPLICATION | PAGE 6
CAI Headquarters Leadership (List specific assignments. Minimum one year of service required.)
FROM DATE (MM/YY) TO DATE (MM/YY) POINT VALUE
TRUSTEE ____________________________________________________________ 25
COMMITTEE CHAIR __________________________________________________ 25
COUNCIL/COMMITTEE MEMBER ______________________________________ 20
CAI Chapter Leadership (List chapter/assignments. Minimum one year of service required.)
FROM DATE (MM/YY) TO DATE (MM/YY) POINT VALUE
PRESIDENT _________________________________________________________ 25
BOARD MEMBER _____________________________________________________ 20
COMMITTEE CHAIR __________________________________________________ 20
COMMITTEE/TASK FORCE MEMBER ___________________________________ 15
COMMITTEE/TASK FORCE MEMBER ___________________________________ 15
COMMITTEE/TASK FORCE MEMBER ___________________________________ 15
ORGANIZING CHAPTER BOARD MEMBER ______________________________ 15
CHAPTER MENTOR __________________________________________________ 15
CHAPTER BUSINESS PLAN DEVELOPER ________________________________ 15
STRATEGIC PLANNING COMMITTEE MEMBER _________________________ 15
SPECIAL EVENT MANAGER (TRADE SHOW, GOLF OUTING, ETC.)
_____________________________________________________________________ 10
OTHER ______________________________________________________________ 10
Speaker at CAI chapter program POINT VALUE
PROGRAM TITLE/TOPIC __________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
PROGRAM TITLE/TOPIC __________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
Exam administrator for CAI or CAMICB programs POINT VALUE
CHAPTER ________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
CHAPTER ________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
CONTINUED ON NEXT PAGE
II. CAI and Industry-Related Organization Service
PCAM APPLICATION | PAGE 7
CAI headquarters speaker
POINT VALUE
TOPIC ___________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
TOPIC ___________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
Speaker for other organization on industry-related subject POINT VALUE
SPONSORING ORGANIZATION/DESCRIPTION ______________________________________________________________________
_________________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
SPONSORING ORGANIZATION/DESCRIPTION _________________________________________________________________________
_________________________________________________________________________________________________________________
DATE (MM/YY) LOCATION
10
Attendance at related organization seminars (3–5 hours = 5 points; 6 hours or more = 10 points) POINT VALUE
SPONSORING ORGANIZATION/TOPIC _____________________________________________________________________________
_________________________________________________________________________________________________________________
DATE (MM/YY) LOCATION HOURS
5/10
SPONSORING ORGANIZATION/TOPIC _____________________________________________________________________________
_________________________________________________________________________________________________________________
DATE (MM/YY) LOCATION HOURS
5/10
SPONSORING ORGANIZATION/TOPIC _____________________________________________________________________________
_________________________________________________________________________________________________________________
DATE (MM/YY) LOCATION HOURS
5/10
Reviewer/developer of a CAI headquarters workshop, course or seminar POINT VALUE
WORKSHOP/DESCRIPTION OF INPUT _____________________________________________________________________________
_________________________________________________________________________________________________________________ 20
WORKSHOP/DESCRIPTION OF INPUT _____________________________________________________________________________
_________________________________________________________________________________________________________________ 20
CONTINUED ON NEXT PAGE
II. CAI and industry-related organization service continued:
PCAM APPLICATION | PAGE 8
II. CAI and industry-related organization service continued:
Authorship of article in CAI or other industry-related publication (Copies of published article must be submitted to
receive credit. 500 word article = 10 points; 1000 word article = 15 points; 1500 word article = 20 points) POINT VALUE
ARTICLE TITLE ___________________________________________________________________________________________________
PUBLICATION NAME _____________________________________________________________________________________________
ISSUE DATE/PUBLISHED
500 1000 1500 WORD ARTICLE 10/15/20
ARTICLE TITLE ___________________________________________________________________________________________________
PUBLICATION NAME _____________________________________________________________________________________________
ISSUE DATE/PUBLISHED
500 1000 1500 WORD ARTICLE 10/15/20
ARTICLE TITLE ___________________________________________________________________________________________________
PUBLICATION NAME _____________________________________________________________________________________________
ISSUE DATE/PUBLISHED
500 1000 1500 WORD ARTICLE 10/15/20
Reviewer of a CAI publication POINT VALUE
TITLE ____________________________________________________________________________________________________________
PUBLICATION ____________________________________________________________________________________________________
ISSUE DATE/REVIEWED
5
TITLE ____________________________________________________________________________________________________________
PUBLICATION ____________________________________________________________________________________________________
ISSUE DATE/REVIEWED
5
Leader in an affiliated organization (List specific assignments.
Minimum one year of service required.) FROM DATE (MM/YY) TO DATE (MM/YY) POINT VALUE
_____________________________________________________________________ 10
_____________________________________________________________________ 10
PCAM APPLICATION | PAGE 9
The Manager Shall:
1. Comply with current bylaws, standards and practices as may be established from time to time by CAI subject
to all federal, state and local laws, ordinances, and regulations in effect where the Manager practices.
2. Participate in continuing professional education through CAI and other industry related organizations.
3. Act in the best interests of the client; refrain from making inaccurate or misleading representations or
statements; not knowingly misrepresent facts to benefit the Manager.
4. Undertake only those engagements that they can reasonably expect to perform with professional competence.
5. Exercise due care and perform planning and supervision as specified in the written management
agreement, job description or duly adopted Board policies.
6. Disclose all relationships in writing to the client regarding any actual, potential or perceived conflict of interest
between the Manager and other vendors. The Manager shall take all necessary steps to avoid any perception of
favoritism or impropriety during the vendor selection process and negotiation of any contracts.
7. Provide written disclosure of any compensation, gratuity or other form of remuneration from individuals or
companies who act or may act on behalf of the client.
8. Insure that homeowners receive timely notice as required by state statutes or legal documents and protect
their right of appeal.
9. Disclose to the client the extent of fidelity or other contractually required insurance carried on behalf
of the Manager and/or client and any subsequent changes in coverage, which occur during the Manager’s
engagement if the amount is lower than the contract amount requires.
10. See that the funds held for the client by the Manager are in separate accounts, are not misappropriated, and
are returned to the client at the end of the Manager’s engagement; Prepare and furnish to the client accurate
and timely financial reports in accordance with the terms of the management agreement, job
description or duly adopted Board policies.
11. Recognize the original records, files and books held by the Manager are the property of the client to be
returned to the client at the end of the Manager’s engagement; maintain the duty of confidentiality
to all current and former clients.
12. Refrain from criticizing competitors or their business practices; Act in the best interests of their Employers;
Maintain a professional relationship with our peers and industry related professionals.
13. Conduct themselves in a professional manner at all times when acting in the scope of their employment.
14. Not engage in any form of price fixing, anti-trust, or anti-competition.
15. Not use the work products of colleagues or competing management firms that are considered proprietary
without the expressed written permission of the author or the management firm.
Compliance with the Professional Manager Code of Ethics is further amplified in the Code Clarification
Document provided by Community Associations Institute.
Last revised September 2006
III. Community Associations Institute
Professional Manager Code of Ethics
PCAM APPLICATION | PAGE 10
III. Code Clarification Document
Last revised 2016
A. Authority
The Code derives its authority from the Community Associations Institute (CAI). CAI’s Board of Trustees
has established a minimum standard of professional ethical performance for those individuals who receive
recognition or designations from CAI.
Those individuals or entities that apply for or hold professional designations from CAI are subject to this
Code. Those designations include: PCAM
®
, AMS
®
, LSM
, and AAMC.
B. Definitions
The Code shall apply in any manager-client relationship where the Manager receives some form of
compensation for professional services offered or provided to the client.
Manager—a singular term which shall apply to all of the following persons or entities providing or offering
some form of property or financial or administrative or consulting services to one or more clients:
a. A single practitioner functioning as a client employee, or
b. A single practitioner employed by a firm contracted by one or more clients, or
c. A principal or supervisory staff member for a firm which is contracted by one or more clients, or
d. A firm, which is contracted by one or more clients, whether it is organized as a corporation,
partnership, or other entity.
Because the Code is designed to establish a standard of conduct for the practice of managing community
associations, it is equally applicable to individuals and firms. An individual who agrees to abide by this
Code shall also be responsible to see that any other person or firm under his/her supervision shall comply
with the Code.
Client—a singular term applying to one or more community association properties (condominium, home-
owner association, cooperative, PUD, PRD, etc.) and their governing body. The client may employ the
Manager directly or be under some form of independent contract with the Manager.
C. Amplification
CAI to further explain and define the Code of Ethics provides the following information.
The following explanations correspond to the numbered paragraphs in the Professional Manager
Code of Ethics:
1. Current standards or practices are those numbered one through fifteen in the Code. Managers who
practice in states with legislative requirements must comply with those laws. Managers shall not discrimi-
nate in any relationship, with any individual or firm, based upon race, color, religion, sex, national origin,
familial status, or handicap and shall comply with all federal, state and local laws concerning discrimina-
tion. Managers shall not engage in any form of price fixing, anti-trust, or anti-competition with other Man-
agers or Vendors.
2. Continuing professional education requirements are consistent with that Manager’s designation. While
CAI membership is not mandatory, the Manager must satisfy the designation requirement in order to use
said designation. Additionally the Manager has a duty to remain informed on relevant matters affecting
the industry.
3. Act in the best interests of the client; Not make any inaccurate or misleading representations or
statements to a prospective client; Not knowingly misrepresent facts to benefit the Manager; the
manager has a fiduciary duty/responsibility to the client and should at all times act in the best interests of
the client. Managers should avoid exaggeration, misrepresentation, concealment, and knowingly distribut-
ing misinformation.
PCAM APPLICATION | PAGE 11
III. Code Clarification Document (continued)
4. Undertake only those engagements that they can reasonably expect to perform with professional
competence; the Manager shall provide accurate information within his area of expertise and refrain from
the unauthorized practice of other professions. No manager should provide any service or advice that is
outside his or her field of competence which includes dispensing of professional advice that falls under the
auspices of other disciplines such as legal representatives, engineers and contractors.
5. Exercise due care and exhibit planning and supervision as specified in the written management agree-
ment, job description, or duly adopted Board policies. The intent of this statement is for the Manager
to make a good faith effort to operate within the framework of the applicable employment/agent relation-
ship and to abide by the terms of said agreement. Any failure of the Manager to fully comply with this
requirement shall not be considered relevant unless the failure is material and/or willful.
6. Disclosure of any possible conflict of interest is the key here. An example may be of assistance. A Man-
ager (individually or through a company) may have financial interest in a service contractor, supplier, or
professional firm that is being considered by that Manager’s client. Disclosure must be in writing and suf-
ficiently in advance of the selection process to allow full consideration of the possible conflicts and any
alternatives. The fact that the client may still choose the Manager’s related entity is not a violation of the
Code, provided ample disclosure was given.
7. Provide written disclosure to the client of any compensation, gratuity or other from of remuneration
from individuals or companies who act or may act on behalf of the client. Written disclosure shall be
made to the client by the Manager, confirming receipt of all commissions, rebates, discounts, payments,
or other benefits received in excess of $200.00 annually by the Manager from any vendor or vendor relat-
ed client.
8. CAI recognizes that insuring that homeowners have timely notice or that their appeal rights are
protected is limited by the extent that the Manager can influence his or her client. Thus, a Manager who
makes reasonable efforts to properly advise the client has complied with this standard, even if the client
chooses to reject the Manager’s advice.
9. Disclose to the client the extent of fidelity or other contractually required insurance carried on behalf of
the Manager and/or client and any subsequent changes in coverage, which occur during the Manager’s
engagement if the amount is lower than the contract amount requires. This standard does not require
the Manager to carry fidelity insurance unless an AAMC company or required by the contract. The change is
based upon any decrease in contractually disclosed/required coverage and/or fidelity bond coverage.
10. If the Manager is responsible for handling funds for a client, that client must have at least one, indepen-
dent cash account. This standard does not preclude a Manager from initially depositing payments into a
central account with funds promptly distributed to individual client accounts, nor does it prohibit a cen-
tral disbursement or payroll account that is promptly reimbursed by each client’s individual cash account.
When a Manager’s engagement has ended for a client, all funds must be returned to the client the earlier
of:
z the time limit under state statute, or
z the time limit in the existing management agreement, or
z within 30 days of the end of the Manager’s engagement (see also #12)
The Manager shall prepare and furnish to the client accurate and timely financial reports in accordance
with the terms of the management agreement, job description or duly adopted Board policies.
11. Original records, files, and books are those items that were given to the Manager at the beginning of
his or her engagement or were developed by the Manager and/or the client during the period of the
Manager’s engagement. This definition may be further expanded by the management agreement. Unless
provided in such an agreement or otherwise, the Manager has no obligation to provide the client with
client-related computerized data unless the client owns the computer and software and such data can be
separated from that data and software which are proprietary to the Manager. For example, if the Manager
is a company that maintains homeowner information on its central computer, the Manager shall provide
a printout of the homeowner information for the client, but need not provide that data via disk or tape.
PCAM APPLICATION | PAGE 12
III. Code Clarification Document (continued)
Those items that the Manager brought to and used during the engagement, such as operation or proce-
dure manuals, remain the property of the Manager.
While the Manager must turn over all records, files, and books, he or she may retain photocopies of those
key materials that might be necessary for the Manager in dealing with post-engagement client-related
matters. Return of these items should be consistent with the schedule outlined in #10 above. The Manager
shall maintain a duty of confidentiality to all current and former clients, commencing the effective start
date of the relationship and continuing through infinity.
12. Refrain from criticizing competitors or their business practices; Act in the best interests of their
Employers; Maintain a professional relationship with our peers and industry related professionals.
13. Shall conduct themselves in a professional manner when acting in the scope of their employment.
Self-explanatory.
14. Subject to all Federal, State and Local statutes, laws and ordinances.
15. Work products that are posted on the internet, e-mailed, presented as part of an education session or
industry related networking exchange are not considered proprietary unless they are clearly labeled as
proprietary documents or subject to further protection under the copyright or registration. Lists of clients
along with their contact and confidential contract information that are maintained by a Management Com-
pany are considered proprietary.
D. Future
The Board of Trustees may expand application of this Code, and CAI reserves the right to update, or
amend both the Professional Manager Code of Ethics and the Code Clarification Document. Any such
revision, updating or amendment shall be promptly promulgated to CAI Manager members and, after due
notice, will apply to all members subject to the Code.
E. E-mail as Official Correspondence
The Board of Trustees establishes e-mail as official correspondence in matters relating to alleged viola-
tions of CAI Professional Manager Code of Ethics. The CAI Designation Ethics Committee, Chief Executive
Officer, or CAI staff designee, may elect to notify and or update a designee of a complaint that has been
filed against their designation by e-mail, and upon doing so will make effort in tracking delivery of corre-
spondence to ensure the designee has the opportunity to respond.
F. Disciplinary Action
After an internal investigation and hearing as provided in CAI’s Ethics Enforcement Procedures Policy, a
Manager found to be in violation of this Code shall face a sanction in accordance with the enforcement
policies adopted by the CAI Board of Trustees. The extent of such sanction shall be commensurate with
the nature, severity, and intent of the violation. In a situation where a firm, principal(s) or supervisory staff
are involved, sanctions may be imposed on more than one individual or the firm itself.
6402 Arlington Blvd., Suite 500
Falls Church, VA 22042
www.caionline.org
(888) 224-4321
III. Code Clarification Document (continued)
Please answer the following questions.
Have you ever been involved in reorganization for the benefit of creditors or in YES NO
bankruptcy as a debtor? If yes, attach a detailed explanation.
Have you ever been convicted of a felony or misdemeanor (equivalents thereof), or YES NO
imprisoned under sentence for any felony or misdemeanor (except traffic violations)?
If yes, attach a detailed explanation.
Have you been found liable or had a judgment or consent decree entered against YES NO
you in civil court related to any business or professional matter or in any other civil case
(with the exception of any domestic or family law, e.g., divorce or child custody)?
If yes, attach a detailed explanation and include a copy of the judgment
entered against you.
Have you ever been convicted of fraud, misrepresentation, misappropriation of YES NO
funds or property? If yes, attach a detailed explanation.
Do you know of any reason why you would be unable to obtain bonding? If yes, YES NO
attach a detailed explanation.
Have you ever been subject to disciplinary action by any professional organization? YES NO
If yes, attach a detailed explanation.
G. Signature
By signing below, I agree to abide by the CAI Professional Manager Code of Ethics and to be subject to
disciplinary action as adopted by the Board of Trustees. All of the information provided by me is complete
and correct to the best of my knowledge and belief. If I made or at any time make statements with
knowledge of its falsity, I understand that it shall be cause for denial or revocation of the designation.
Further, if any circumstance changes my answer to any of the questions above, I will notify CAI Education/
Designations Department by providing a written statement and detailed explanation within 30 days. I will
address the statement and detailed explanation to: CAI Designations Department, 6402 Arlington Blvd.,
Suite 500, Falls Church, VA 22042 or info@caionline.org.
PRINTED NAME SIGNATURE
FIRM NAME (IF EMPLOYED BY A FIRM OR ARE A PRINCIPAL OR SUPERVISORY STAFF MEMBER OF THE FIRM)
PRINTED NAME AND SIGNATURE OF AN OFFICER OF THAT FIRM, IF APPLICABLE