Fill and Sign the 254 Form

7.25[4] Form: General Questionnaire for Potential Nominees to Boards Of Directors In using the following form of Questionnaire, please keep in mind that not all questions may be applicable or appropriate in your particular setting. Heavily regulated industries such as gaming may demand much more detailed and delicate disclosure, and other industries or situations (such as privately held corporations) may require much less disclosure. Consider the circumstances of each situation, and modify this form as appropriate. To: Potential Nominees to Board of Directors of __________________ (the "Company") Copies: Executive Officers, Present Board of Directors Members [list other appropriate addressees, or convert to letter format for individual addressees] From: Chairman of the Board [Nominating Company, or other Relevant Officer or Body] Date: ____________________ Re: Questionnaire for Potential Board of Directors Nominees This Questionnaire is being submitted in accord with the Company's policies and practices regarding the nomination of persons to be considered for seats on the Company's board of directors, and its due diligence activities related to each such candidate. In order to advance the Board's consideration of your candidacy, you must complete the following Questionnaire. Some of this information may be used in connection with one or more background checks. In such case, you will receive a separate "Consent to Background Check" from the Company, authorizing the release of certain information regarding you to the Company. Please answer all questions completely and accurately to the best of your knowledge and ability. Completed forms should be signed and returned to the following on or before _______________: [Insert all relevant contact information for the person charged with timely collection of Questionnaires.] General Information Current Employment/Position/Title:_______________________ Current Employer:________________________________________ Office Address: __________________________________________ _________________________________________________________ Home Address:__________________________________________ _________________________________________________________ Office Telephone: ______________________________________ Home Telephone: ______________________________________ Cell Phone (optional)____________________________________ E-mail Address: ________________________________________ Birth Date: ____________________________________________ Birth Place: ___________________________________________ I am a U.S. citizen ___ I am not a U.S. citizen ___ Social Security Number: _______________________________ Drivers License State and Number: ________________________ ¥ Have you ever been known by any other name or surname or used any other Social Security numbers? If yes, state all names or Social Security numbers used and dates of use: ___________________________ _________________________________________________________________ ¥ Have you ever been accused, indicted or convicted of any criminal activity? If so, please describe: ________________________ _________________________________________________________________ ¥ Have you ever been the subject of any disciplinary or other proceeding involving any governmental, professional or other organization? If so, please describe: _____________________________ _________________________________________________________________ ¥ Please describe any circumstances that would prevent you from attending regular board meetings or completing a full ____ year term on the Company's board of directors: _________________________ _________________________________________________________________ ¥ Please describe briefly why you wish to serve on the Company's board: __________________________________________________________ _________________________________________________________________ (use separate sheet if more space required). ¥ Please describe some of your special talents and experience that would make you an asset to the Company's board of directors: _________________________________________________________________ _________________________________________________________________ ¥ Based on your current knowledge of the Company, the industry sector and the economy at large, please describe some of the major opportunities or challenges that you believe confront the Company today: __________________________________________________________ _________________________________________________________________ Educational Background Graduate Schools Attended: (School) (City & State) Dates of Attendance: From to Degree: Date Awarded: Colleges or Universities Attended: (School) (City & State) (Dates Attended) (Degree) (School) (City & State) (Dates Attended) (Degree) (School) (City & State) (Dates Attended) (Degree) (School) (City & State) (Dates Attended) (Degree) If you have ever been dismissed from or disciplined by any such educational institution, please describe: ___________________________ ___________________________________________________________________ Employment and Business Ownership and Involvement ¥ Please identify in reverse chronological order the names of all corporations, firms, or other business enterprises, partnerships, nonprofit organizations, and educational or other institutions with which you are now or have ever been in the past connected as an employee, officer, owner, director, trustee, partner, advisor, or consultant, including dates and titles associated with the affiliation. You do not need to identify publicly traded businesses in which you were only a stockholder and never had any involvement other than buying or selling less than 1% of the securities and never had any position on the Board, as an employee, officer or consultant or in management of the business: ___________________________________________________________________ ___________________________________________________________________ ¥ Please describe the nature of any contractual or informal arrangement you may have with any business enterprise in regard to future employment or future involvement as an independent contractor: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been affiliated with a business enterprise in which there were allegations of fraud or accounting improprieties? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been affiliated with a business enterprise that experienced serious financial downturn or sought protection (or threatened to seek protection) under the bankruptcy laws? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ Government Positions ¥ Please describe any positions that you currently hold or have ever held in any federal, state, or local government (foreign or domestic), together with the dates associated with the position(s): ___________________________________________________________________ ___________________________________________________________________ ¥ Please describe any military service that you have provided, together with ranks held, dates of service, and the nature of your discharge: ___________________________________________________________________ ___________________________________________________________________ Organization Membership ¥ Please list each membership you have had or currently hold with any civic, social, charitable, educational, political, professional, fraternal, benevolent, nonprofit, private club, recreational organization (golf club, country club, tennis club, health club, etc.), or other membership organization. Please include dates of membership and any positions you have held: ___________________________________________________________________ ___________________________________________________________________ ¥ Do any of the membership organizations listed above have any membership restrictions? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Do any of the membership organizations listed above discriminate on the basis of race, sex, age, or national origin or maintain policies regarding such discrimination? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ Financial ¥ On an attachment to this Questionnaire, please provide the names of all corporations, partnerships or other institutions in which you have, or in the past five years have had, any financial interests through the ownership of stock, stock options, bonds, partnership interests, equity, or other arrangements, including trusts. There is no need to identify publicly held businesses in which you have never owned more than 1% of the business's securities. ¥ On an attachment to this Questionnaire, please provide the names of all corporations, firms, or other business enterprises, partnerships, nonprofit organizations, and education or other institutions, with which you have any continuing financial interests through present employment or by reason of a pension or retirement plan, stock bonus, profit-sharing, or other arrangement as a result of any current or prior employment or business or professional association. Please describe the nature of such continuing financial interests. ¥ On an attachment to this Questionnaire, please list all your interests in real property, other than a personal residence or vacation home, setting forth the nature of your interest, the type of property, and the address. ¥ Have your wages, earnings, or other income ever been subject to garnishment, attachment, charging order, voluntary wage execution or the like? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever declared bankruptcy personally? If yes, please explain, providing relevant dates and describing resolution: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been involved in any commercial dispute, including, but not limited to, disputes over real estate, financial issues, or private business matters? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been involved in any investigation or allegations over financial matters brought by any federal, state or local authorities? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ Civil, Criminal and Investigatory Proceedings ¥ Have you ever been involved in civil or criminal litigation, or administrative or legislative proceedings of any kind, either as plaintiff, defendant, respondent, witness, or party in interest? If yes, please provide full details including dates, issues litigated, resolution, and the location where the civil action is recorded: ___________________________________________________________________ ___________________________________________________________________ ¥ Has any business concern you ever owned, controlled, served as a director for, or were employed by or affiliated with, been charged with any crime or offense? If yes, please provide full details, including relevant dates, nature of charge, resolution, and the location where the criminal action is recorded: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you, or any business concern you ever owned, controlled, served as a director for, or were employed by or affiliated with, been the target or subject of investigation conducted by any governmental agency, court, committee, grand jury, or investigatory body? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been called to testify or requested to take a polygraph exam before any governmental agency, court, committee, grand jury, or investigatory body? If yes, please explain the nature and circumstances of your testimony: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been granted immunity by any federal, state or local authorities, or sought assurances from law enforcement authorities that you would not be prosecuted? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ Prior Investigations ¥ Have you ever been the subject of prior background checks, investigations, confirmation hearings, or government clearance checks? If yes, please explain any issues that were raised: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been denied government clearance or confirmation to any position? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been involved in any type of ethics investigation? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ Publicity ¥ Have you ever been publicly identified, in person or by organizational membership or affiliation, with a particularly controversial national or local issue? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Have you ever been involved in any other public controversy not covered by the preceding question? If yes, please explain: ___________________________________________________________________ ___________________________________________________________________ ¥ Is there any other information, including information about other members of your family, that could be considered a possible source of embarrassment to you or your family? ___________________________________________________________________ ___________________________________________________________________ Certification I hereby certify that the information provided in the answers above is complete and truthful. Signature:Date: