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<br />- <br /> <br />SIGNATURE PAGE <br /> <br />. <br /> <br />INSTRUCTIONS FOR COMPLETING THE SIGNATURE PAGE <br />Your completion of the signature page is required for BNY Clearing to open and maintain your account. When completing the signature <br />page, you mllst sign Section I (All Accounts) and Section 2 (Substitute W-9). <br /> <br />Account Number <br />Name (see specific instructions on the back) <br />Business name. if different from above <br />Address (number, street and apartment or suite number) <br />City, state and zip code <br /> <br />0-fy ~ f- <br /> <br />~eMo'I/,/0 <br /> <br />ALL ACCOUNTS <br /> <br />SECTION 1 (SIGNATURE REQUIRED) <br />By signing this Agreement, lackuowledge that I have received copies of this Agreement and the "Notice to Introduced Customers". I have <br />reed this agreement and understand and agree that my account with BNY Clearing will be governed by the provisions of this Agreement. <br /> <br />BY SIGNING TillS AGREEMENT, I ACKNOWLEDGE THAT MY SECURITIES MAY BE LOANED TO YOU OR LOANED <br />OUT TO OTHERS TO THE EXTENT PERMITTED BY APPLICABLE LAWS AND REGULATIONS. <br /> <br />TillS AGREEMENT CONTAINS A PRE-DISPUTE ARBITRATION CLAUSE SET FORTH IN PARAGRAPH 26 OF THE <br />CUSTOMER ACCOUNT AGREEMENT & DISCLOSURE DOCUMENT. BY MY SIGNATURE BELOW, I ACKNOWELDGE <br />THAT I HAVE READ AND AGREE TO BE BOUND BY ALL THE TERMS AND CONDmONS OF TillS AGREEMENT AND <br />THAT J HAVE RECEIVED A COPY OF TillS AGREEMENT. <br /> <br />Print Name <br /> <br />Print Name <br /> <br />Signature <br /> <br />SUBSTITUTE FORM W-9 <br /> <br />SECTION 2 (SIGNATURE REQUIRED) <br />Certification - Under penalties of peIjury, I certifY that: <br />1. The number shown on this fonn is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and <br />2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have uot been uotified by the <br />Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (e) The <br />IRS has notified me that I am no longer subject to backup withholding, and <br />3. I am a U.S. person (including a U.s. resident alien). <br /> <br />Certification Instructions - You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup <br />withholding because you bave failed to report all interest or dividends on your tax retum. For real estate transactions, item 2 does not apply. <br />For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement <br />arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must <br />provide your correct TIN. (See the instructions on back of page.) <br /> <br />Check appropriate box: 0 Individual/Sole Proprietor <br /> <br />o Corporation OPartnership 0 Other <br /> <br />&]J /)f ~eltkr0 (tv <br />Name .Ass ated with the number indicated <br /> <br />X <br />/ Signature ofUB, Person Date <br /> <br />Social Security Number <br /> <br />1/... 1:2-&;,70/'-/ <br />Employer Identification Number <br /> <br />Northland Securities, Inc. . 45 South 7th Street. Suite 2500 . Minneapolis, MN 5540Z . 1-80Q...851.Z920 . www.northlandsecurities.com <br />NAlOO1(10102) <br />