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Ss City State M M / D D / M Date of Birth M / D D / Date of Hire Y Y Y Y Zip M M M / M / D D D D / / Y Y Y Y Social Security Number STEP 2: PLEASE READ BELOW AND COMPLETE ACCORDINGLY I elect to participate in the 401(k) by making a Salary Deferral Contribution* in the amount described below: Pre-Tax 1-40% of pay each pay period. I understand that if I join the 401(k), I must return a Designation of Beneficiary Form, no matter what I elect. *I have receive.

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