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Date
MM slash DD slash YYYY
COMPANY NAME:
TICKER:
CLASS PERIOD:
LEAD PLAINTIFF MOTION DEADLINE:
Shareholder Contact Information
Name*
First Name* Last Name*
Email*
Phone
Address
Street City State / Province / Region ZIP / Postal Code Country
Are you a current or former employee of ?*
- Yes
- No
Transactions in the Company
Number of shares of held immediately before the start of the Class Period ()
During the Class Period (), I made the following transactions in :
Purchases
Date
MM slash DD slash YYYY

Price
No. of Shares
Sales
Date
MM slash DD slash YYYY

Price
No. of Shares
Post Class Period Sales
During the 90 days after Class Period, I made the following transactions:
Date
MM slash DD slash YYYY

Price
No. of Shares
Did you purchase/sell options during the Class Period?*
- Yes
- No
Estimated Losses
Comments or Questions
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I agree to the Berman Tabacco Disclaimer*
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Shareholder Contact Information