Rule 630-X-4-.02(8)

ELECTION PETITION FORM-APPENDIX B

We herewith submit the name of ___________________________________________________

as a nominee for consideration by this annual meeting.

This ____________ day of ______________________, ________.

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Signature - License number

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Signature - License number

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Signature - License number

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Signature - License number

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Signature - License number

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Signature - License number

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Signature - License number