APPENDIX I
KVH INDUSTRIES, INC.
STOCK CERTIFICATE QUESTIONNAIRE
Pursuant to Sections 3 of the Agreement, please provide us with the
following information:
1. The exact name that your Shares are to be registered in (this is the
name that will appear on your stock certificate(s)). You may use a nominee name
if appropriate:
2. The relationship between the Purchaser of the Shares and the Registered
Holder listed in response to item 1 above:
3. The mailing address of the Registered Holder listed in response to item
1 above:
4. The Social Security Number or Tax Identification Number of the
Registered Holder listed in response to item 1 above:
