APPENDIX III
PURCHASER'S CERTIFICATE OF SUBSEQUENT SALE
The undersigned, an officer of, or other person duly authorized by
[fill in official name of individual or institution]
hereby certifies that he/she/it is the Purchaser of the shares evidenced by the
attached certificate, and as such, sold such shares on ________________, 200__
in accordance with Registration Statement number ________________, and complied
with the requirement of delivering a current prospectus in connection with such
sale.
Print or Type:
Name of Purchaser (Individual or Institution):
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Name of Individual representing Purchaser (if an Institution)
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Title of Individual representing Purchaser (if an Institution):
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Signature:
Individual Purchaser or Individual representing Purchaser:
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