Investor Information Request

First Name: Last Name: Title: Company:	Phone: Email: Website:
Address:	City: State/Province:
Zip:	Country:

Lead Source:	Product Interest:
Additional Information:

Investor relations:
Nicole Acton
Document Security Systems, Inc.
28 East Main Street, Suite 1525
Rochester, NY 14614
(585) 325-3610
Email Investor Relations

Shareholder info and certificate work:
American Stock Transfer
& Trust Co.
Attn: Shareholders Relations
59 Maiden Lane
NY, NY 10038
718.921.8210