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<div class=3DSection1>

<p class=3DMsoTitle>Education Registrant Reference/Evaluation List</p>

<h2 align=3Dleft style=3D'text-align:left'><span style=3D'mso-tab-count:1'>=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><=
span
style=3D'font-size:13.0pt;mso-bidi-font-size:10.0pt'><o:p></o:p></span></h2>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:10.0pt;font-=
family:
Tahoma'><o:p>&nbsp;</o:p></span></b></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'>NAME
_____________________________________<span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;
</span>STUDENT ID # ____________________<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:center 3.25in'><b style=3D'mso-bidi=
-font-weight:
normal'><span style=3D'font-size:10.0pt;font-family:Tahoma'><span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp; </span>IMPORTANT!!
-- READ CAREFULLY <o:p></o:p></span></b></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:9.0pt;font-family:Tahoma'>In order for us to maintain
references in your Reference File, we <b style=3D'mso-bidi-font-weight:norm=
al'><i
style=3D'mso-bidi-font-style:normal'>must</i></b> have your written
authorization.<span style=3D'mso-spacerun:yes'>&nbsp; </span>List below the=
 names
of the people from whom you will be requesting references/evaluations.<span
style=3D'mso-spacerun:yes'>&nbsp; </span>Put your initials and the current =
date
in the spaces provided below in order to authorize the <st1:place w:st=3D"o=
n"><st1:PlaceName
 w:st=3D"on">Career</st1:PlaceName> <st1:PlaceType w:st=3D"on">Center</st1:=
PlaceType></st1:place>
to maintain your references when they are returned to the office.<span
style=3D'mso-spacerun:yes'>&nbsp; </span>Indicate in the first column the t=
ype of
reference so that we can provide you with the appropriate reference form.<s=
pan
style=3D'mso-spacerun:yes'>&nbsp; </span><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-top:0in;margin-right:.25in;margin-bott=
om:0in;
margin-left:.25in;margin-bottom:.0001pt;tab-stops:-1.0in -.5in .25in .5in'>=
<b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'>To add a reference/evaluation not previously listed:</span></b><span
style=3D'font-size:9.0pt;font-family:Tahoma'><o:p></o:p></span></p>

<p class=3DMsoBodyTextIndent style=3D'mso-margin-bottom-alt:auto'><span
style=3D'font-size:9.0pt'>add name, initial in &quot;..TO ADD OR KEEP...&qu=
ot;
column, date in &quot;CURRENT DATE&quot; column and request a
reference/evaluation form from the <st1:place w:st=3D"on"><st1:PlaceName w:=
st=3D"on">Career</st1:PlaceName>
 <st1:PlaceType w:st=3D"on">Center</st1:PlaceType></st1:place>.<b
style=3D'mso-bidi-font-weight:normal'><o:p></o:p></b></span></p>

<p class=3DMsoNormal style=3D'margin-top:0in;margin-right:.25in;margin-bott=
om:0in;
margin-left:.25in;margin-bottom:.0001pt;tab-stops:-1.0in -.5in .25in .5in'>=
<b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'>To keep a reference/evaluation already listed:<o:p></o:p></span></b=
></p>

<p class=3DMsoBodyTextIndent style=3D'mso-margin-bottom-alt:auto'><span
style=3D'font-size:9.0pt'>initial in &quot;..TO ADD OR KEEP...&quot; column=
 and
date in &quot;CURRENT DATE&quot; column.<b style=3D'mso-bidi-font-weight:no=
rmal'><o:p></o:p></b></span></p>

<p class=3DMsoNormal style=3D'margin-top:0in;margin-right:.25in;margin-bott=
om:0in;
margin-left:.25in;margin-bottom:.0001pt;tab-stops:-1.0in -.5in .25in .5in'>=
<b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'>To delete any reference/evaluation:</span></b><span style=3D'font-s=
ize:
9.0pt;font-family:Tahoma'><span style=3D'mso-spacerun:yes'>&nbsp; </span><o=
:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:.5in;tab-stops:-1.0in -.5in .25in=
 .5in'><span
style=3D'font-size:9.0pt;font-family:Tahoma'>initial in &quot;..REF/EVAL.
DELETED...&quot; column and date in &quot;CURRENT DATE&quot; column.<span
style=3D'mso-spacerun:yes'>&nbsp; </span>Deleted references/evaluations wil=
l be
destroyed.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:9.0pt;font-family:Tahoma'>Employers are mainly intereste=
d in <b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'>current</i></b>
references/evaluations.<span style=3D'mso-spacerun:yes'>&nbsp; </span>If yo=
u have
a file several years old, you may want to request that certain
references/evaluations be deleted.<span style=3D'mso-spacerun:yes'>&nbsp;
</span>We do not recommend that you include personal or character
references/evaluations in your file.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-top:0in;margin-right:.25in;margin-bott=
om:0in;
margin-left:.25in;margin-bottom:.0001pt;tab-stops:-1.0in -.5in .25in .5in'>=
<b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'><o:p>&nbsp;</o:p></span></b></p>

<p class=3DMsoNormal style=3D'margin-top:0in;margin-right:.25in;margin-bott=
om:0in;
margin-left:.25in;margin-bottom:.0001pt;tab-stops:-1.0in -.5in .25in .5in'>=
<b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'>*For Beginning Teachers this list of evaluations should include:</s=
pan></b><span
style=3D'font-size:9.0pt;font-family:Tahoma'><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:.5in;tab-stops:-1.0in -.5in .25in=
 .5in'><span
style=3D'font-size:9.0pt;font-family:Tahoma'>Cooperating Teacher(s), Univer=
sity
Supervisor(s)/Liaison(s), and Building Administrator(s) who have first&#820=
9;hand
knowledge of your student teaching.<span style=3D'mso-spacerun:yes'>&nbsp;
</span>Secondary teachers may want to consider a reference from a faculty
member in their major field of study.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:.25in;tab-stops:-1.0in -.5in .25i=
n .5in'><b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'><o:p>&nbsp;</o:p></span></b></p>

<p class=3DMsoNormal style=3D'margin-left:.25in;tab-stops:-1.0in -.5in .25i=
n .5in'><b
style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:9.0pt;font-f=
amily:
Tahoma'>*For Experienced Teachers this list of references should include:</=
span></b><span
style=3D'font-size:9.0pt;font-family:Tahoma'><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:.5in;tab-stops:-1.0in -.5in .25in=
 .5in'><span
style=3D'font-size:9.0pt;font-family:Tahoma'>Building Administrators or
Superintendents.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:center 3.25in'><b style=3D'mso-bidi=
-font-weight:
normal'><i style=3D'mso-bidi-font-style:normal'><span style=3D'font-size:10=
.0pt;
font-family:Tahoma'><span style=3D'mso-tab-count:1'> </span>You should keep=
 your
file updated by adding recent references/evaluations from employers as you
change jobs and by deleting out&#8209;dated references/evaluations.</span><=
/i></b><span
style=3D'font-size:10.0pt;font-family:Tahoma'><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'tab-stops:-1.0in -.5in .25in .5in'><b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'><span
style=3D'font-size:10.0pt;font-family:Tahoma'><span
style=3D'mso-spacerun:yes'>&nbsp;</span><o:p></o:p></span></i></b></p>

<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'><span
style=3D'font-size:10.0pt;font-family:Tahoma'>LIMIT # OF REFERENCES/EVALUAT=
IONS
TO SIX (6).<span style=3D'mso-spacerun:yes'>&nbsp; </span></span></i></b><i
style=3D'mso-bidi-font-style:normal'><span style=3D'font-size:10.0pt;font-f=
amily:
Tahoma'>Forms will be provided by the <st1:place w:st=3D"on"><st1:PlaceName
 w:st=3D"on">Career</st1:PlaceName> <st1:PlaceType w:st=3D"on">Center</st1:=
PlaceType></st1:place>.<span
style=3D'mso-spacerun:yes'>&nbsp; </span></span></i><span style=3D'font-siz=
e:10.0pt;
font-family:Tahoma'><span style=3D'mso-spacerun:yes'>&nbsp;</span>Many scho=
ol
districts consider a file &quot;complete&quot; if it has three or more
references/evaluations.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><i
style=3D'mso-bidi-font-style:normal'><span style=3D'font-size:10.0pt;font-f=
amily:
Tahoma'><o:p>&nbsp;</o:p></span></i></p>

<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><i
style=3D'mso-bidi-font-style:normal'><span style=3D'font-size:10.0pt;font-f=
amily:
Tahoma'><o:p>&nbsp;</o:p></span></i></p>

<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'><span
style=3D'font-size:10.0pt;font-family:Tahoma'>I authorize the university to
accept the following references on my behalf with the understanding that th=
ese
references become the property of the university.<span
style=3D'mso-spacerun:yes'>&nbsp; </span></span></i></b><span style=3D'font=
-size:
10.0pt;font-family:Tahoma;mso-bidi-font-weight:bold'>References/evaluations=
 we
receive that you have not listed, initialed, and dated, will be returned to=
 the
author.</span><i style=3D'mso-bidi-font-style:normal'><span style=3D'font-s=
ize:
8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;mso-bidi-font-weight:bol=
d'><o:p></o:p></span></i></p>

<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'><span
style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o:p=
>&nbsp;</o:p></span></i></b></p>

<table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi=
dth=3D700
 style=3D'width:525.0pt;margin-left:-29.1pt;border-collapse:collapse;border=
:none;
 mso-border-alt:solid black .75pt;mso-padding-alt:0in 5.4pt 0in 5.4pt;
 mso-border-insideh:.75pt solid black;mso-border-insidev:.75pt solid black'>
 <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;height:29.65pt'>
  <td width=3D154 valign=3Dtop style=3D'width:115.5pt;border:double black 2=
.25pt;
  padding:0in 5.4pt 0in 5.4pt;height:29.65pt'>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'><span
  style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp; </span>*Type of Refer=
ence<o:p></o:p></span></b></p>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'>(i.e. Cooperating
  Teacher, <o:p></o:p></span></b></p>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'><span
  style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Li=
aison,
  Principal)<o:p></o:p></span></b></p>
  </td>
  <td width=3D306 valign=3Dtop style=3D'width:229.45pt;border:double black =
2.25pt;
  border-left:none;mso-border-left-alt:double black 2.25pt;padding:0in 5.4p=
t 0in 5.4pt;
  height:29.65pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><b style=3D'ms=
o-bidi-font-weight:
  normal'><span style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-fam=
ily:
  Tahoma;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></span></b></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'><span
  style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;
  </span>Name of Reference Writer<o:p></o:p></span></b></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:double blac=
k 2.25pt;
  border-left:none;border-bottom:double black 2.25pt;border-right:solid bla=
ck 1.0pt;
  mso-border-left-alt:double black 2.25pt;mso-border-alt:double black 2.25p=
t;
  mso-border-right-alt:solid black .75pt;padding:0in 5.4pt 0in 5.4pt;
  height:29.65pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><b style=3D'ms=
o-bidi-font-weight:
  normal'><span style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-fam=
ily:
  Tahoma;mso-bidi-font-style:italic'>Initial to Add/Keep Reference<o:p></o:=
p></span></b></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.45pt;border:double black 2.=
25pt;
  border-left:none;mso-border-left-alt:solid black .75pt;padding:0in 5.4pt =
0in 5.4pt;
  height:29.65pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'>Current<o:p></o:p><=
/span></b></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-size:8.0pt;mso-=
bidi-font-size:
  10.0pt;font-family:Tahoma;mso-bidi-font-style:italic'><span
  style=3D'mso-spacerun:yes'>&nbsp; </span>Date<o:p></o:p></span></b></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:double blac=
k 2.25pt;
  border-left:none;border-bottom:double black 2.25pt;border-right:solid bla=
ck 1.0pt;
  mso-border-left-alt:double black 2.25pt;mso-border-alt:double black 2.25p=
t;
  mso-border-right-alt:solid black .75pt;padding:0in 5.4pt 0in 5.4pt;
  height:29.65pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><b style=3D'ms=
o-bidi-font-weight:
  normal'><span style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-fam=
ily:
  Tahoma;mso-bidi-font-style:italic'>Initial to Delete Reference<o:p></o:p>=
</span></b></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.5pt;border:double black 2.2=
5pt;
  border-left:none;mso-border-left-alt:solid black .75pt;padding:0in 5.4pt =
0in 5.4pt;
  height:29.65pt'>
  <p class=3DMsoBodyText align=3Dleft style=3D'text-align:left'><b style=3D=
'mso-bidi-font-weight:
  normal'><span style=3D'font-family:Tahoma'>Current Date</span></b><b
  style=3D'mso-bidi-font-weight:normal'><span style=3D'font-family:Tahoma;
  mso-bidi-font-style:normal'><o:p></o:p></span></b></p>
  </td>
 </tr>
 <tr style=3D'mso-yfti-irow:1;height:18.75pt'>
  <td width=3D154 valign=3Dtop style=3D'width:115.5pt;border-top:none;borde=
r-left:
  solid black 1.0pt;border-bottom:solid black 1.0pt;border-right:double bla=
ck 2.25pt;
  mso-border-top-alt:double black 2.25pt;mso-border-top-alt:double 2.25pt;
  mso-border-left-alt:solid .75pt;mso-border-bottom-alt:solid .75pt;mso-bor=
der-right-alt:
  double 2.25pt;mso-border-color-alt:black;padding:0in 5.4pt 0in 5.4pt;
  height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:nor=
mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
:p>&nbsp;</o:p></span></i></b></p>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D306 valign=3Dtop style=3D'width:229.45pt;border-top:none;bord=
er-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:double black 2.25pt;mso-border-left-alt:double black 2=
.25pt;
  mso-border-alt:double black 2.25pt;mso-border-bottom-alt:solid black .75p=
t;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:double black 2.25pt;mso-border-left-alt:double black 2=
.25pt;
  mso-border-top-alt:double 2.25pt;mso-border-left-alt:double 2.25pt;
  mso-border-bottom-alt:solid .75pt;mso-border-right-alt:solid .75pt;
  mso-border-color-alt:black;padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.45pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:double black 2.25pt;mso-border-left-alt:solid black .7=
5pt;
  mso-border-top-alt:double 2.25pt;mso-border-left-alt:solid .75pt;mso-bord=
er-bottom-alt:
  solid .75pt;mso-border-right-alt:double 2.25pt;mso-border-color-alt:black;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:double black 2.25pt;mso-border-left-alt:double black 2=
.25pt;
  mso-border-top-alt:double 2.25pt;mso-border-left-alt:double 2.25pt;
  mso-border-bottom-alt:solid .75pt;mso-border-right-alt:solid .75pt;
  mso-border-color-alt:black;padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.5pt;border-top:none;border-=
left:none;
  border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;mso-border=
-top-alt:
  double black 2.25pt;mso-border-left-alt:solid black .75pt;mso-border-alt:
  solid black .75pt;mso-border-top-alt:double black 2.25pt;padding:0in 5.4p=
t 0in 5.4pt;
  height:18.75pt'>
  <p class=3DMsoNormal style=3D'mso-pagination:widow-orphan'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
 </tr>
 <tr style=3D'mso-yfti-irow:2;height:18.75pt'>
  <td width=3D154 valign=3Dtop style=3D'width:115.5pt;border-top:none;borde=
r-left:
  solid black 1.0pt;border-bottom:solid black 1.0pt;border-right:double bla=
ck 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-alt:solid black .75pt;
  mso-border-right-alt:double black 2.25pt;padding:0in 5.4pt 0in 5.4pt;
  height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:nor=
mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
:p>&nbsp;</o:p></span></i></b></p>
  </td>
  <td width=3D306 valign=3Dtop style=3D'width:229.45pt;border-top:none;bord=
er-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
  mso-border-top-alt:solid .75pt;mso-border-left-alt:double 2.25pt;mso-bord=
er-bottom-alt:
  solid .75pt;mso-border-right-alt:double 2.25pt;mso-border-color-alt:black;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
  mso-border-alt:solid black .75pt;mso-border-left-alt:double black 2.25pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.45pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:solid black .75p=
t;
  mso-border-alt:solid black .75pt;mso-border-right-alt:double black 2.25pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D66 valign=3Dtop style=3D'width:49.55pt;border-top:none;border=
-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
  mso-border-alt:solid black .75pt;mso-border-left-alt:double black 2.25pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
  <td width=3D54 valign=3Dtop style=3D'width:40.5pt;border-top:none;border-=
left:none;
  border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;mso-border=
-top-alt:
  solid black .75pt;mso-border-left-alt:solid black .75pt;mso-border-alt:so=
lid black .75pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.75pt'>
  <p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69=
.9pt -15.9pt 2.1pt'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma;
  mso-bidi-font-weight:bold;mso-bidi-font-style:italic'><o:p>&nbsp;</o:p></=
span></p>
  </td>
 </tr>
 <tr style=3D'mso-yfti-irow:3;height:18.75pt'>
  <td width=3D154 valign=3Dtop style=3D'width:115.5pt;border-top:none;borde=
r-left:
  solid black 1.0pt;border-bottom:solid black 1.0pt;border-right:double bla=
ck 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-alt:solid black .75pt;
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bottom:
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er-left:
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bottom:
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bottom:
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mal'><span
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bottom:
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mal'><span
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bottom:
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mal'><span
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left:none;
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bottom:
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mal'><span
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:p>&nbsp;</o:p></span></i></b></p>
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r-left:
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ck 2.25pt;
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bottom:
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mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
:p>&nbsp;</o:p></span></i></b></p>
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er-left:
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5pt;
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bottom:
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
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bottom:
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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mal'><span
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mal'><span
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left:none;
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bottom:
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mal'><span
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r-left:
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ck 2.25pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
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er-left:
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  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
  mso-border-top-alt:solid .75pt;mso-border-left-alt:double 2.25pt;mso-bord=
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bottom:
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-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:solid black .75p=
t;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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mal'><span
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left:none;
  border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;mso-border=
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lid black .75pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:nor=
mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
:p>&nbsp;</o:p></span></i></b></p>
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r-left:
  solid black 1.0pt;border-bottom:solid black 1.0pt;border-right:double bla=
ck 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-alt:solid black .75pt;
  mso-border-right-alt:double black 2.25pt;padding:0in 5.4pt 0in 5.4pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
  0in;margin-left:.6pt;margin-bottom:.0001pt;tab-stops:-105.9pt -69.9pt -15=
.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:nor=
mal'><span
  style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o=
:p>&nbsp;</o:p></span></i></b></p>
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er-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
  mso-border-top-alt:solid .75pt;mso-border-left-alt:double 2.25pt;mso-bord=
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
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mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:double black 2.25pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:solid black .75p=
t;
  mso-border-alt:solid black .75pt;mso-border-right-alt:double black 2.25pt;
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  <p class=3DMsoNormal style=3D'margin-top:0in;margin-right:-33.9pt;margin-=
bottom:
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.9pt 2.1pt'><b
  style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:nor=
mal'><span
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-left:
  none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;
  mso-border-top-alt:solid black .75pt;mso-border-left-alt:double black 2.2=
5pt;
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bottom:
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.9pt 2.1pt'><b
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mal'><span
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bottom:
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.9pt 2.1pt'><b
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mal'><span
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<p class=3DMsoNormal style=3D'margin-right:-33.9pt;tab-stops:-105.9pt -69.9=
pt -15.9pt 2.1pt'><b
style=3D'mso-bidi-font-weight:normal'><i style=3D'mso-bidi-font-style:norma=
l'><span
style=3D'font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Tahoma'><o:p=
>&nbsp;</o:p></span></i></b></p>

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