EFTA Document EFTA01453157

Are you an employee or related to an employee of Financial Industry Regulatory Authority/other self-regulatory organization? K Yes K No If Yes, list person and organization: Is any owner now, or has any owner ever been, a senior corporate officer or director, or does any owner own 10% or more of any publicly-traded company's stock? K Yes K No If Yes, provide name of company, publicly traded symbol and affiliation date: 3rd Authorized Party's Personal Information Name DOB. SSN: