N. _______________  "___"_________ 199_ 
   +--------------------------------------------------------------------+
                                 
                    .                             
                                      .    
   +--------------+------------------------------+----------------------
                                                                     
                                                                     
                                                                     
                                                                     
                                                                     
                                                                     
                                                                     
                                                                     
                                                                     
   +--------------+------------------------------+----------------------
                                                                
   +--------------------------------------------------------------------+
   
            _______________________________
    .
            ____________________________
    .
   
    -                     
    ________________________                   ___________________