Automatic Monthly Deductions Authorization Agreement
EXHIBIT 99.3
| FILL IN THE INFORMATION BELOW FOR STOCK PURCHASES USING AUTOMATIC MONTHLY DEDUCTIONS. |
| Please Print All items |
| 1. Type of Account Checking Savings |
| Bank account Number |
| a. Name of Bank Account |
| Financial Institution |
| Branch Name |
| Branch Street Address |
| Branch City. State and Zip Code |
| $ ABA Number Amount of automatic deduction |
| PLEASE CONFIRM ITEMS 2 AND 5 WITH YOUR BANK PRIOR TO SUBMITTING THIS APPLICATION. |
| Name on bank account |
| XXXX X. XXX XXXX X. XXX |
| 000 XXXX XXXXXX |
| ANYWHERE. U.S.A. 12345 03850 |
| 670 |
| PAY TO THE |
| ORDER OF___$ |
| Financial institution and branch information |
| DOLLARS |
| First National Bank of Anywhere 000 Xxxx Xxxxxx Xxxxxxxx, X.X.X. 12345 |
| FOR___SAMPLE (NON-NEGOTIABLE) |
| 07100013 123456789 |
| ABA Number Bank Account Number |
S-19
