31.04.06.04

.04 Sample Questionnaire.

(1) Do you or does any member of your family have any relationships or engage in any activities that might impair your independence of judgment concerning Company business?

Yes _______ No________

(2) Do you or does any member of your family have any personal financial interests that might impair your independence of judgment or influence your decisions or actions concerning Company business in the direction of such personal financial interests?

Yes_______ No_______

(3) Have you accepted gifts, benefits, or unusual hospitality that might tend in any way to impair your independence of judgment or affect your decisions or actions concerning Company business?

Yes________ No_______

(If your answer to any of the foregoing three questions is yes, please attach to this questionnaire a full explanation.)

___________________ ______________________________
Dated Signature
______________________________ Position