+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   |                     | >  |   |              |
|  1 |              |       |   |                     |  2 |   |              |
| \. |              |       |   |                     | \. |   |              |
| >  |              |       |   |                     | >  |   |              |
|  P |              |       |   |                     | SA |   |              |
| RO |              |       |   |                     | MP |   |              |
| DU |              |       |   |                     | LE |   |              |
| CT |              |       |   |                     | >  |   |              |
| >  |              |       |   |                     |  N |   |              |
| >  |              |       |   |                     | O. |   |              |
|    |              |       |   |                     | >  |   |              |
|    |              |       |   |                     | >  |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              | > b\. |   |                     |    |   |              |
|  3 |              | >     |   |                     |    |   |              |
| a. |              | LABOR |   |                     |    |   |              |
| >  |              | ATORY |   |                     |    |   |              |
| SA |              | > C   |   |                     |    |   |              |
| MP |              | ONCLU |   |                     |    |   |              |
| LE |              | SIONS |   |                     |    |   |              |
| >  |              | >     |   |                     |    |   |              |
| CL |              | >     |   |                     |    |   |              |
| AS |              |       |   |                     |    |   |              |
| SI |              |       |   |                     |    |   |              |
| FI |              |       |   |                     |    |   |              |
| CA |              |       |   |                     |    |   |              |
| TI |              |       |   |                     |    |   |              |
| ON |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| *( |              |       |   |                     |    |   |              |
| In |              |       |   |                     |    |   |              |
| se |              |       |   |                     |    |   |              |
| rt |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| cl |              |       |   |                     |    |   |              |
| as |              |       |   |                     |    |   |              |
| si |              |       |   |                     |    |   |              |
| fi |              |       |   |                     |    |   |              |
| ca |              |       |   |                     |    |   |              |
| ti |              |       |   |                     |    |   |              |
| on |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| co |              |       |   |                     |    |   |              |
| de |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  f |              |       |   |                     |    |   |              |
| or |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  e |              |       |   |                     |    |   |              |
| ac |              |       |   |                     |    |   |              |
| h\ |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  P |              |       |   |                     |    |   |              |
| AC |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  N |              |       |   |                     |    |   |              |
| o. |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  r |              |       |   |                     |    |   |              |
| ep |              |       |   |                     |    |   |              |
| re |              |       |   |                     |    |   |              |
| se |              |       |   |                     |    |   |              |
| nt |              |       |   |                     |    |   |              |
| ed |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| by |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  s |              |       |   |                     |    |   |              |
| am |              |       |   |                     |    |   |              |
| pl |              |       |   |                     |    |   |              |
| e. |              |       |   |                     |    |   |              |
| )* |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  | PAC NO.      |       |   |                     |    |   |              |
| CO |              |       |   |                     |    |   |              |
| DE |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       | > |                     |    | > |              |
|  c |              |       |   |                     |    |   |              |
| \. |              |       | d |                     |    | e |              |
| >  |              |       | \ |                     |    | \ |              |
| NA |              |       | . |                     |    | . |              |
| ME |              |       | > |                     |    | > |              |
| >  |              |       |   |                     |    |   |              |
|  A |              |       | S |                     |    | D |              |
| ND |              |       | I |                     |    | A |              |
| >  |              |       | G |                     |    | T |              |
|  T |              |       | N |                     |    | E |              |
| IT |              |       | A |                     |    | > |              |
| LE |              |       | T |                     |    | > |              |
| >  |              |       | U |                     |    |   |              |
| >  |              |       | R |                     |    |   |              |
|    |              |       | E |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   |                     |    |   |              |
|  4 |              |       |   |                     |    |   |              |
| a. |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| DI |              |       |   |                     |    |   |              |
| ST |              |       |   |                     |    |   |              |
| RI |              |       |   |                     |    |   |              |
| CT |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  C |              |       |   |                     |    |   |              |
| ON |              |       |   |                     |    |   |              |
| CL |              |       |   |                     |    |   |              |
| US |              |       |   |                     |    |   |              |
| IO |              |       |   |                     |    |   |              |
| NS |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   | > c\. SIGNATURE     |    |   | > d\. DATE   |
|  b |              |       |   |                     |    |   | >            |
| \. |              |       |   |                     |    |   | >            |
| >  |              |       |   |                     |    |   |              |
| NA |              |       |   |                     |    |   |              |
| ME |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  A |              |       |   |                     |    |   |              |
| ND |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  T |              |       |   |                     |    |   |              |
| IT |              |       |   |                     |    |   |              |
| LE |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| *( |              |       |   |                     |    |   |              |
| Di |              |       |   |                     |    |   |              |
| st |              |       |   |                     |    |   |              |
| ri |              |       |   |                     |    |   |              |
| ct |              |       |   |                     |    |   |              |
| )* |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+

**FORM FDA 465 (4/78**) PREVIOUS EDITION IS OBSOLETE **SAMPLE SUMMARY**

+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   |                     | >  |   |              |
|  1 |              |       |   |                     |  2 |   |              |
| \. |              |       |   |                     | \. |   |              |
| >  |              |       |   |                     | >  |   |              |
|  P |              |       |   |                     | SA |   |              |
| RO |              |       |   |                     | MP |   |              |
| DU |              |       |   |                     | LE |   |              |
| CT |              |       |   |                     | >  |   |              |
| >  |              |       |   |                     |  N |   |              |
| >  |              |       |   |                     | O. |   |              |
|    |              |       |   |                     | >  |   |              |
|    |              |       |   |                     | >  |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              | > b\. |   |                     |    |   |              |
|  3 |              | >     |   |                     |    |   |              |
| a. |              | LABOR |   |                     |    |   |              |
| >  |              | ATORY |   |                     |    |   |              |
| SA |              | > C   |   |                     |    |   |              |
| MP |              | ONCLU |   |                     |    |   |              |
| LE |              | SIONS |   |                     |    |   |              |
| >  |              | >     |   |                     |    |   |              |
| CL |              | >     |   |                     |    |   |              |
| AS |              |       |   |                     |    |   |              |
| SI |              |       |   |                     |    |   |              |
| FI |              |       |   |                     |    |   |              |
| CA |              |       |   |                     |    |   |              |
| TI |              |       |   |                     |    |   |              |
| ON |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| *( |              |       |   |                     |    |   |              |
| In |              |       |   |                     |    |   |              |
| se |              |       |   |                     |    |   |              |
| rt |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| cl |              |       |   |                     |    |   |              |
| as |              |       |   |                     |    |   |              |
| si |              |       |   |                     |    |   |              |
| fi |              |       |   |                     |    |   |              |
| ca |              |       |   |                     |    |   |              |
| ti |              |       |   |                     |    |   |              |
| on |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| co |              |       |   |                     |    |   |              |
| de |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  f |              |       |   |                     |    |   |              |
| or |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  e |              |       |   |                     |    |   |              |
| ac |              |       |   |                     |    |   |              |
| h\ |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  P |              |       |   |                     |    |   |              |
| AC |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  N |              |       |   |                     |    |   |              |
| o. |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  r |              |       |   |                     |    |   |              |
| ep |              |       |   |                     |    |   |              |
| re |              |       |   |                     |    |   |              |
| se |              |       |   |                     |    |   |              |
| nt |              |       |   |                     |    |   |              |
| ed |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| by |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  s |              |       |   |                     |    |   |              |
| am |              |       |   |                     |    |   |              |
| pl |              |       |   |                     |    |   |              |
| e. |              |       |   |                     |    |   |              |
| )* |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  | PAC NO.      |       |   |                     |    |   |              |
| CO |              |       |   |                     |    |   |              |
| DE |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       | > |                     |    | > |              |
|  c |              |       |   |                     |    |   |              |
| \. |              |       | d |                     |    | e |              |
| >  |              |       | \ |                     |    | \ |              |
| NA |              |       | . |                     |    | . |              |
| ME |              |       | > |                     |    | > |              |
| >  |              |       |   |                     |    |   |              |
|  A |              |       | S |                     |    | D |              |
| ND |              |       | I |                     |    | A |              |
| >  |              |       | G |                     |    | T |              |
|  T |              |       | N |                     |    | E |              |
| IT |              |       | A |                     |    | > |              |
| LE |              |       | T |                     |    | > |              |
| >  |              |       | U |                     |    |   |              |
| >  |              |       | R |                     |    |   |              |
|    |              |       | E |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   |                     |    |   |              |
|  4 |              |       |   |                     |    |   |              |
| a. |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| DI |              |       |   |                     |    |   |              |
| ST |              |       |   |                     |    |   |              |
| RI |              |       |   |                     |    |   |              |
| CT |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  C |              |       |   |                     |    |   |              |
| ON |              |       |   |                     |    |   |              |
| CL |              |       |   |                     |    |   |              |
| US |              |       |   |                     |    |   |              |
| IO |              |       |   |                     |    |   |              |
| NS |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+
| >  |              |       |   | > c\. SIGNATURE     |    |   | > d\. DATE   |
|  b |              |       |   |                     |    |   | >            |
| \. |              |       |   |                     |    |   | >            |
| >  |              |       |   |                     |    |   |              |
| NA |              |       |   |                     |    |   |              |
| ME |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  A |              |       |   |                     |    |   |              |
| ND |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|  T |              |       |   |                     |    |   |              |
| IT |              |       |   |                     |    |   |              |
| LE |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| *( |              |       |   |                     |    |   |              |
| Di |              |       |   |                     |    |   |              |
| st |              |       |   |                     |    |   |              |
| ri |              |       |   |                     |    |   |              |
| ct |              |       |   |                     |    |   |              |
| )* |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
| >  |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
|    |              |       |   |                     |    |   |              |
+----+--------------+-------+---+---------------------+----+---+--------------+

**FORM FDA 465 (4/78**) PREVIOUS EDITION IS OBSOLETE **SAMPLE SUMMARY**