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Shareholder Information Change Form
Dear Member,

Please see if your listing is correct. If you find an error please make a correction on this form and give it to President, Ron Schafer. The correction will be made. Thank you for your patience and understanding. We would appreciate a periodic check of your member information and updates as needed.

Name Okay ______  Address Okay ______  Phone/Fax/E-mail Okay _____

THE FOLLOWING CORRECTION IS NEEDED:

Name _______________________________________________

Group # _______________

Address ______________________________________________

_____________________________________________________

Phone # (        )__________________________

Fax # (           ) _____________________________

E-mail ________________________________________________

Signed _________________________________________________

Date ___________________

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