|                   |   |                  |   |                      |   |                 |
|------------------------|--------|-----------------------|--------|---------------------------|--------|----------------------|
| Last Name              |   | First Name            |   | MI                        |   | Sex (M or F)         |
|                   |   |                  |   |                      |   |                 |
|                   |   |                  |   |                      |   |                 |
| Social Security Number |   | Date of Birth(mmddyy) |   | Employee #(if applicable) |   | Date of Hire(mmddyy) |
|                   |   |                  |   |                      |   |                 |
|                   |   |                  |   |                      |   |                 |
| Home phone             |   | Work phone            |   |                      |   |                 |

|            |   |   |   |   |
|-----------------|--------|--------|--------|--------|
| Street Address  |
|            |   |   |   |   |
|            |   |   |   |   |
| Mailing Address |
|            |   |   |   |   |
|            |   |   |   |   |
| City            |   | State  |   | Zip    |

| _____  |   | Yes, I want to make pre-tax deferral contributions to the Plan.  I authorize the Bank to deduct the following percentage (no more than 100%) of my compensation from each paycheck and to credit that amount to pre-tax deferral portion of my Account: |
|--------|--------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|   |   |                                                                                                                                                                                                                                                              |
|   | _____  | Fee/Salary (if applicable)                                                                                                                                                                                                                                        |
|   |   |                                                                                                                                                                                                                                                              |
|   | _____  | Bonus (if applicable)                                                                                                                                                                                                                                             |
|   |   |                                                                                                                                                                                                                                                              |
|   | _____  | Other                                                                                                                                                                                                                                                             |
|   |   |                                                                                                                                                                                                                                                              |
| _____  |   | No, I do not wish to contribute to the Plan at this time.                                                                                                                                                                                                         |

|   | _____ | one hundred twenty (120) equal monthly installments |
|--------|-------|-----------------------------------------------------|

----

|        |   |   |
|-------------|--------|--------|
| Participant |   | Date   |