EFTA Document EFTA01367493

The i.ndinifined hereby acknowledges that 0 the Informedon contained in this form is complete and aocurate to the best knowledge of the undersigned- and tie the urcerregneo is resronsiole for the method of transmission of any instructions issued pursuant to this authorization. If the undersigned elects to banding any such :n;:ruvons via fax (including desktop fax). via email or es an image attachment to amad (e.g., as a PDF, TIF or other image of such instructions). the undersigned understand