| ☐ $52.25 | | | ☐ $53.75 | | | ☐ $55.25 | | | ☐ $56.75 | | | ☐ $58.25 | | | ☐ $59.75 | |
| ☐ $52.50 | | | ☐ $54.00 | | | ☐ $55.50 | | | ☐ $57.00 | | | ☐ $58.50 | | | ☐ $60.00 | |
| ☐ $52.75 | | | ☐ $54.25 | | | ☐ $55.75 | | | ☐ $57.25 | | | ☐ $58.75 | | | | |
| ☐ $53.00 | | | ☐ $54.50 | | | ☐ $56.00 | | | ☐ $57.50 | | | ☐ $59.00 | | | | |
| ☐ $53.25 | | | ☐ $54.75 | | | ☐ $56.25 | | | ☐ $57.75 | | | ☐ $59.25 | | | | |
| ☐ $53.50 | | | ☐ $55.00 | | | ☐ $56.50 | | | ☐ $58.00 | | | ☐ $59.50 | | | | |
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指定招揽经纪人
(见函中的说明14) |
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| | 仅当您希望指定经纪人有资格收取招揽交易商费用时才填写。 | | | |||
| | 招揽经纪人名称: | | |
(please print)
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| | 招揽经纪人地址: | | |
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Signature(s) |
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Name(s) |
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纳税人身份或社保号码: |
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Address(es) |
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电话号码(含区号) |
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