Company: ______________________________________________

Company Location:______________________________________________

Date:_________________        Time: ____________

  ___ Phone call

  ___ Meeting      Location: ____________________

Recommended that I:     ___ buy         ___ sell

Name of security: _________________________________________

How does this recommendation meet my investment objectives? What are the specific reasons why I should invest in this? (or sell this?)

___________________________________________________________

___________________________________________________________

___________________________________________________________

What are the specific risks if I buy this investment?

____________________________________________________________

____________________________________________________________

____________________________________________________________

I asked to receive written information about this investment before making a decision:

    ___ yes         ___ no

I asked for:

___ a prospectus

___ most recent annual report (10K)

___ most recent quarterly report (10Q)

___ any other recent report (8K)

___ any other available written material

___ other _____________________

After looking at the written material, I decided to:

___ do nothing

___ buy

___ sell

how much? _______________

at what price? _______________

The total cost of this transaction will be: _______________

Other Notes:

Date: __________________________