| How much money did you lose?
$ ___________________
Do you have any physical handicap, illness or other condition that would limit your physical dexterity and mental capacity to Day Trade securities (trading is a computer keyboard skill that requires fast hand-to-eye coordination, and computer agility) such as: arthritis, sprained or fractured finger/wrist/arm/shoulder, depression/ schizophrenia, etc): Are you a felon ? Explain:
Where did you trade? Remote by Internet: ____ At Trading Office: ____ Other? Explain: What is the last grade/year of school completed? Did you ever day trade before? Over how long a period? Dates: from to (month/year). Margin Account? Yes Loan Account? Yes No Did the firm loan you $? Yes No Did other Traders loan or pool $ for you? Yes
No
How long a training course did the firm supply? Weeks:
What was the cost of the training course? $
Did you ever trade before?
Yes
No
Name of Day Trading/Broker Dealer firm: Address: City/State/Zip: CEO/Principal: Office Mgr: Operating Chief: Tech Support:
Did this firm maintain a “NASDAQ” Trading Station “Unit on the Floor?” Yes No
What provision was immediately available to you as a back-out to ‘break’ a faulty trade or unwind an error? Was there back-up power supply? Yes No
Explain: Was there alternate connections to SOES, Island, etc. Yes No
Do you have your monthly Statements? Yes No
Do you have daily Statements? Yes No
Do you have a list of all securities traded? Yes No
Did you experience any of the following? Electrical power failure? Yes
No
Yes No
Lost connection to NASDAQ; Yes
No
NYSE, Yes No
Am. Stk. Exchange, Yes No
Select Net, Yes No
SOES, Yes
No
Island, Yes
No
Did the Island (or other ECN) ever give you a partial fill? Yes
No
Ever get an overfill? Yes
No
Instanet, Yes
No
Yes
No
Errors in Accounting and bookkeeping? Yes No
Clearing House or Broker Dealer debit your account prior or margin call/receipt? Yes No
Post premium dating? Yes
No
Unauthorized charges to your account? Yes
No
Wire Transfer charges? Yes
No
Failure to timely respond to complaints or correct errors? Yes No
Failure to correct over charges or remove improper charges? Yes
No
Failure to timely post? Yes
No
Other deceptive, unfair or oppressive practices? Explain:
We will review the information you have provided and may decide that additional investigation or action is warranted. In the event that we have additional questions or need additional information, please indicate how we can alert you of our continuing interest. If you would like us to contact you, please fill in the following information. Name and all information is optional, but an e-mail address or some other way, at least, is necessary for us to respond. You may remain anonymous or use a screen alias or pen name. Name: E-mail: Postal
Tel/Fx: There is no review fee for administrative time to review this.
However, after our review there is a fee of $100.00 to be further considered
for inclusion in our class action to see if you qualify.
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