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Exhibit 10.3
 
NEITHER THIS SECURED CONVERTIBLE NOTE NOR THE SECURITIES INTO WHICH THIS
CONVERTIBLE NOTE ARE CONVERTIBLE HAVE BEEN REGISTERED WITH THE SECURITIES AND
EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE.  THIS SECURED
CONVERTIBLE NOTE HAS BEEN SOLD IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION
UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND,
ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE
REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE
EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE
SECURITIES LAWS.
 
American Power Corp.
 
Secured Convertible Note
 
 
Issuance Date:     
Original Principal Amount:   $_________.00
No. AMPW-1-__
 

FOR VALUE RECEIVED, American Power Corp., a Nevada corporation (the “Company”),
hereby promises to pay to the order of YA Global Master SPV, Ltd. or its
registered assigns (the “Holder”) (i) the outstanding portion of the amount set
out above as the Original Principal Amount (as reduced pursuant to the terms
hereof pursuant to redemption, conversion or otherwise, the “Principal”) when
due, whether upon the Maturity Date (as defined below), acceleration, redemption
or otherwise (in each case in accordance with the terms hereof) and (ii) to pay
interest (“Interest”) on any outstanding Principal at the applicable Interest
Rate from the date set out above as the Issuance Date (the “Issuance Date”)
until the same is paid, whether upon the Maturity Date or acceleration,
conversion, redemption or otherwise (in each case in accordance with the terms
hereof).  Certain capitalized terms used herein are defined in Section 16.
 
(1) GENERAL TERMS
 
(a) Advance of Original Principal Amount.  In consideration for the issuance of
this Note by the Company, on the Issuance Date the Holder shall advance and make
available to the Company the Original Principal Amount by wire transfer of
immediately available funds to the account indicated by the Company on Schedule
I attached hereto.  
 
(b) Maturity Date. The term of this Senior Note (this “Note”) shall expire on
August 13, 2012 (the “Maturity Date”).  On the Maturity Date, the Company shall
pay to the Holder an amount in cash representing all outstanding Principal and
accrued and unpaid Interest.  
 
(c) Payments.  Principal and Interest (if any) owed under this Note must be paid
by wire transfer of immediately available funds to the account listed on
Schedule II hereto (or to any other account specified by the Holder to the
Company) by the Maturity Date.  Other than as specifically permitted by this
Note, the Company may not prepay or redeem any portion of the outstanding
Principal without the prior written consent of the Holder.
 
 
 
 

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(d) Interest.  Interest shall accrue on the outstanding Principal balance hereof
at a rate equal to 8% per annum.  Interest shall be calculated on the basis of a
365-day year and the actual number of days elapsed, to the extent permitted by
applicable law.
 
(e) Security.  The Note is secured by a pledge of ___________ shares of the
Company’s common stock (the “Common Stock”), par value $0.001 per share as
evidenced by the Pledge Agreement of even date herewith (the “Pledge
Agreement”).
 
(2) COMPANY REDEMPTION.  Provided, that the VWAP of the Common Stock on the
Redemption Date (as defined herein) is less than the Conversion Price, the
Company may following 5 Business Days advanced written notice (such notice, a
“Redemption Notice” and the date on which such Redemption Notice is received,
the “Redemption Date”) to the Holder, redeem all or a portion of the Principal
outstanding and Interest due under this Note (the “Redemption Amount”) before
the Maturity Date by wire transfer of immediately available funds to the account
listed on Schedule II hereto (or to any other account specified by the Holder to
the Company in writing).  Any Redemption Amount will be allocated to outstanding
principal or accrued and unpaid interest at the discretion of the Holder.
 
(3) CONVERSION OF NOTE.  This Note shall be convertible into Common Stock, on
the terms and conditions set forth in this Section 3.
 
(a) Conversion Right.  Subject to the provisions of Section 3(c), at any time or
times on or after the Issuance Date, the Holder shall be entitled to convert any
portion of the outstanding and unpaid Principal and accrued Interest (the
“Conversion Amount”) into fully paid and nonassessable shares of Common Stock in
accordance with Section 3(b), at the Conversion Rate (as defined below).  The
number of shares of Common Stock issuable upon conversion of any Conversion
Amount pursuant to this Section 3(a) shall be determined by dividing (x) such
Conversion Amount by (y) the $__1 (the “Conversion Price”).  The Company shall
not issue any fraction of a share of Common Stock upon any conversion.  If the
issuance would result in the issuance of a fraction of a share of Common Stock,
the Company shall round such fraction of a share of Common Stock up to the
nearest whole share.  The Company shall pay any and all transfer, stamp and
similar taxes that may be payable with respect to the issuance and delivery of
Common Stock upon conversion of any Conversion Amount.
 
(b) Mechanics of Conversion.
 
(i) Optional Conversion.  To convert any Conversion Amount into shares of Common
Stock on any date (a “Conversion Date”), the Holder shall transmit by facsimile
(or otherwise deliver), for receipt on or prior to 11:59 p.m., New York Time, on
such date, a copy of an executed notice of conversion in the form attached
hereto as Exhibit I (the “Conversion Notice”) to the Company.  On or before the
third Business Day following the date of receipt of a Conversion Notice (the
“Share Delivery Date”), the Company shall (a) if legends are not required to be
placed on certificates of Common Stock pursuant to the Note Purchase Agreement,
credit such aggregate number of shares of Common Stock to which the Holder shall
be entitled to the Holder’s or its designee’s balance account with DTC through
its Deposit Withdrawal Agent Commission system or (b) if legends are required to
be placed on certificates of Common Stock pursuant to the Note Purchase
Agreement, issue and deliver to the address as specified in the Conversion
Notice, a certificate, registered in the name of the Holder or its designee, for
the number of shares of Common Stock to which the Holder shall be entitled which
certificate shall bear a restrictive legend as required pursuant to the Note
Purchase Agreement.  The Company shall at all times reserve and keep available
out of its authorized Common Stock the full number of shares of Common Stock
issuable upon conversion of all outstanding amounts under this Note.
 

   

1 The average VWAP over the 3 trading days prior the note issuance date.
 
 
 

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(ii) Company’s Failure to Timely Convert.
 
(1) If within three Trading Days after the Company’s receipt of a Conversion
Notice the Company shall fail to issue and deliver a certificate to the Holder
or credit the Holder’s balance account with DTC for the number of shares of
Common Stock to which the Holder is entitled upon such holder’s conversion of
any Conversion Amount (a “Conversion Failure”), and if on or after such Trading
Day the Holder purchases (in an open market transaction or otherwise) Common
Stock to deliver in satisfaction of a sale by the Holder of Common Stock
issuable upon such conversion that the Holder anticipated receiving from the
Company (a “Buy-In”), then the Company shall, within three Business Days after
the Holder’s request and in the Holder’s discretion, either (i) pay cash to the
Holder in an amount equal to the Holder’s total purchase price (including
brokerage commissions and other out of pocket expenses, if any) for the shares
of Common Stock so purchased (the “Buy-In Price”), at which point the Company’s
obligation to deliver such certificate (and to issue such Common Stock) shall
terminate, or (ii) promptly honor its obligation to deliver to the Holder a
certificate or certificates representing such Common Stock and pay cash to the
Holder in an amount equal to the excess (if any) of the Buy-In Price over the
product of (A) such number of shares of Common Stock, times (B) the Closing Bid
Price on the Conversion Date.
 
(2) Nothing herein shall limit a Holder’s right to pursue actual damages or
declare an Event of Default pursuant to Section 4 herein for the Company’s
failure to deliver certificates representing shares of Common Stock upon
conversion within the period specified herein and such Holder shall have the
right to pursue all remedies available to it at law or in equity including,
without limitation, a decree of specific performance and/or injunctive relief,
in each case without the need to post a bond or provide other security. The
exercise of any such rights shall not prohibit the Holder from seeking to
enforce damages pursuant to any other Section hereof or under applicable law.
 
(iii) Book-Entry. Notwithstanding anything to the contrary set forth herein,
upon conversion of any portion of this Note in accordance with the terms hereof,
the Holder shall not be required to physically surrender this Note to the
Company unless (A) the full Conversion Amount represented by this Note is being
converted or (B) the Holder has provided the Company with prior written notice
(which notice may be included in a Conversion Notice) requesting reissuance of
this Note upon physical surrender of this Note.  The Holder and the Company
shall maintain records showing the Principal and Interest converted and the
dates of such conversions or shall use such other method, reasonably
satisfactory to the Holder and the Company, so as not to require physical
surrender of this Note upon conversion.
 
 
 
 

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(c) Limitations on Conversions.
 
(i) Beneficial Ownership.  The Company shall not effect any conversions of this
Note and the Holder shall not have the right to convert any portion of this Note
or receive shares of Common Stock as payment of interest hereunder to the extent
that after giving effect to such conversion or receipt of such interest payment,
the Holder, together with any affiliate thereof, would beneficially own (as
determined in accordance with Section 13(d) of the Exchange Act and the rules
promulgated thereunder) in excess of 4.99% of the number of shares of Common
Stock outstanding immediately after giving effect to such conversion or receipt
of shares as payment of interest.  Unless the conversion at issue would result
in the issuance of shares of Common Stock in excess of 4.99% of the then
outstanding shares of Common Stock without regard to any other shares which may
be beneficially owned by the Holder or an affiliate thereof, the Holder shall
have the authority and obligation to determine whether the restriction contained
in this Section will limit any particular conversion hereunder and to the extent
that the Holder determines that the limitation contained in this Section
applies, the determination of which portion of the principal amount of this Note
is convertible shall be the responsibility and obligation of the Holder.  If the
Holder has delivered a Conversion Notice for a principal amount of this Note
that, without regard to any other shares that the Holder or its affiliates may
beneficially own, would result in the issuance in excess of the permitted amount
hereunder, the Company shall notify the Holder of this fact and shall honor the
conversion for the maximum principal amount permitted to be converted on such
Conversion Date in accordance with Section 4(a) and, any principal amount
tendered for conversion in excess of the permitted amount hereunder shall remain
outstanding under this Note. The provisions of this Section may be waived by a
Holder (but only as to itself and not to any other holder) upon not less than 65
days prior notice to the Company.
 
(4) EVENTS OF DEFAULT.
 
(a) An “Event of Default”, wherever used herein, means any one of the following
events (whatever the reason and whether it shall be voluntary or involuntary or
effected by operation of law or pursuant to any judgment, decree or order of any
court, or any order, rule or regulation of any administrative or governmental
body) shall have occurred and be continuing:
 
(i) the Company’s failure to pay to the Holder any amount of Principal, Interest
or other amounts when and as due and payable under this Note;
 
(ii) the Company or any subsidiary of the Company shall commence, or there shall
be commenced against the Company or any subsidiary of the Company under any
applicable bankruptcy or insolvency laws as now or hereafter in effect or any
successor thereto, or the Company or any subsidiary of the Company commences, or
there shall be commenced against the Company or any subsidiary of the Company,
any other proceeding under any reorganization, arrangement, adjustment of debt,
relief of debtors, dissolution, insolvency or liquidation or similar law of any
jurisdiction whether now or hereafter in effect relating to the Company or any
subsidiary of the Company, in each case which remains undismissed for a period
of 61 days; or the Company or any subsidiary of the Company is adjudicated
insolvent or bankrupt pursuant to a final, non-appealable order; or any order of
relief or other order approving any such case or proceeding is entered; or the
Company or any subsidiary of the Company suffers any appointment of any
custodian, private or court appointed receiver or the like for it or any
substantial part of its property which continues undischarged or unstayed for a
period of 61 days; or the Company or any subsidiary of the Company makes a
general assignment for the benefit of creditors; or the Company or any
subsidiary of the Company shall fail to pay, or admit in writing that it is
unable to pay, its debts generally as they become due; or the Company or any
subsidiary of the Company shall call a meeting of its creditors with a view to
arranging a composition, adjustment or restructuring of its debts; or any
corporate or other action is taken by the Company or any subsidiary of the
Company for the purpose of effecting any of the foregoing;
 
 
 
 

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(iii) the Common Stock ceases to be quoted or listed for trading on the OTC
Bulletin Board and shall not again be quoted or listed for trading on any
Principal Market within five Trading Days of such delisting;
 
(iv) the Company is a party to any agreement memorializing (1) the consummation
of any transaction or event (whether by means of a share exchange or tender
offer applicable to the Common Stock, a liquidation, consolidation,
recapitalization, reclassification, combination or merger of the Company or a
sale, lease or other transfer of all or substantially all of the consolidated
assets of the Company) or a series of related transactions or events pursuant to
which all of the outstanding shares of Common Stock are exchanged for, converted
into or constitute solely the right to receive, cash, securities or other
property, (2) a consolidation or merger in which the Company is not the
surviving corporation, or (3) a sale, assignment, transfer, conveyance or other
disposal of all or substantially all of the properties or assets of the Company
to another person or entity (each of (1), (2) and (3) a “Change in Control”)
unless in connection with such Change in Control, all Principal and accrued and
unpaid Interest due under this Note will be paid in full or the Holder consents
to such Change in Control;
 
(v) the Company shall fail to observe or perform any other covenant, agreement
or warranty contained in, or otherwise commit any breach or default of any
provision of this Note or the Standby Equity Distribution Agreement (the
“SEDA”), between the Company and the Holder which is not cured within the time
prescribed in this Note or in the SEDA, as applicable or if not so prescribed,
within ten day after notice to the Company by the Holder of such failure, breach
or default;
 
(vi) the Company shall terminate the SEDA; or
 
(vii) an event of default by the Company under any other material obligation,
instrument, note or agreement for borrowed money beyond any applicable notice
and/or grace period, and as a result of which the obligations of the Company in
excess of $250,000 under such obligation, instrument, note or agreement have
been accelerated.
 
 
 
 

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(5) Remedy Upon Default. During the time that any portion of this Note is
outstanding, if (i) any Event of Default has occurred, the Holder, by notice in
writing to the Company, may at any time and from time to time declare the full
unpaid Principal of this Note or any portion thereof, together with Interest
accrued thereon to be due and payable immediately (the “Accelerated Amount”) or
(ii) any Event of Default specified in Section 3(a)(ii) has occurred, the unpaid
Principal of the Note and the Interest accrued thereon shall be immediately and
automatically due and payable without necessity of further action. In addition,
for so long as an Event of Default has occurred and remains uncured, the Company
shall pay default interest at the rate of 18% per annum until the applicable
Event of Default is cured. Such declaration may be rescinded and annulled by
Holder at any time prior to payment hereunder. No such rescission or annulment
shall affect any subsequent Event of Default or impair any right consequent
thereon.
 
(6) REISSUANCE OF THIS NOTE.  Upon receipt by the Company of evidence reasonably
satisfactory to the Company of the loss, theft, destruction or mutilation of
this Note, and, in the case of loss, theft or destruction, of any
indemnification undertaking by the Holder to the Company in customary form and,
in the case of mutilation, upon surrender and cancellation of this Note, the
Company shall execute and deliver to the Holder a new Note representing the
outstanding Principal which Note (i) shall be of like tenor with this Note, (ii)
shall represent, as indicated on the face of such new Note, the Principal
remaining outstanding (iii) shall have an issuance date, as indicated on the
face of such new Note, which is the same as the Issuance Date of this Note, (iv)
shall have the same rights and conditions as this Note, and (v) shall represent
accrued and unpaid Interest from the Issuance Date.
 
(7) NOTICES.                      Any notices, consents, waivers or other
communications required or permitted to be given under the terms hereof must be
in writing and will be deemed to have been delivered:  (i) upon receipt, when
delivered personally; (ii) upon receipt, when sent by facsimile (provided
confirmation of transmission is mechanically or electronically generated and
kept on file by the sending party); or (iii) one (1) Trading Day after deposit
with a nationally recognized overnight delivery service, in each case properly
addressed to the party to receive the same.  The addresses and facsimile numbers
for such communications shall be:
 

If to the Company, to:
 American Power Corp.
 
16 Market Square Centre
 
1400 16th Street Suite 400
Denver, CO 80202
 
Attention:  Johannes Petersen
 
Telephone:        (720) 932-8389
 
Facsimile:           (720) 932-8189
   
With a copy to:
Davis Graham & Stubbs LLP
 
1550 17th Street, Suite 500
 
Denver, CO 80202
 
Attention:  Michelle Shepston
 
Telephone: (303) 892-7344
 
Facsimile: (303) 893-1379

 
 
 

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If to the Holder:
YA Global Master SPV, Ltd.
 
101 Hudson Street, Suite 3700
 
Jersey City, NJ  07302
 
Attention:                      Mark Angelo
 
Telephone:                      (201) 985-8300
   
With a copy to:
David Gonzalez, Esq.
 
101 Hudson Street – Suite 3700
 
Jersey City, NJ 07302
 
Telephone:                      (201) 985-8300
 
Facsimile:                      (201) 985-8266
   

or at such other address and/or facsimile number and/or to the attention of such
other person as the recipient party has specified by written notice given to
each other party three Business Days prior to the effectiveness of such
change.  Written confirmation of receipt (i) given by the recipient of such
notice, consent, waiver or other communication, (ii) mechanically or
electronically generated by the sender’s facsimile machine containing the time,
date, recipient facsimile number and an image of the first page of such
transmission or (iii) provided by a nationally recognized overnight delivery
service, shall be rebuttable evidence of personal service, receipt by facsimile
or receipt from a nationally recognized overnight delivery service in accordance
with clause (i), (ii) or (iii) above, respectively.
 
(8) No provision of this Note shall alter or impair the obligations of the
Company, which are absolute and unconditional, to pay the Principal of or
Interest (if any) on, this Note at the time, place, and rate, and in the
currency, herein prescribed.  This Note is a direct obligation of the Company.
As long as this Note is outstanding, the Company shall not and shall cause its
subsidiaries not to, without the consent of the Holder, (i) amend its articles
of incorporation, bylaws or other charter documents so as to adversely affect
any rights of the Holder under this Note; or (ii) enter into any agreement with
respect to any of the foregoing.
 
(9) This Note shall not entitle the Holder to any of the rights of a stockholder
of the Company, including without limitation, the right to vote, to receive
dividends and other distributions, or to receive any notice of, or to attend,
meetings of stockholders or any other proceedings of the Company, unless and to
the extent converted into shares of Common Stock in accordance with the terms
hereof.
 
(10) This Note shall be governed by and interpreted in accordance with the laws
of the State of New Jersey, without regard to the principles of conflict of
laws.  Each of the parties consents to the jurisdiction of the Superior Courts
of the State of New Jersey sitting in Hudson County, New Jersey and the
U.S. District Court for the District of New Jersey sitting in Newark, New Jersey
in connection with any dispute arising under this Note and hereby waives, to the
maximum extent permitted by law, any objection, including any objection based on
forum non conveniens to the bringing of any such proceeding in such
jurisdictions.
 
 
 
 

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(11) If an Event of Default has occurred, then the Company shall reimburse the
Holder promptly for all fees, costs and expenses, including, without limitation,
attorneys’ fees and expenses incurred by the Holder in any action in connection
with this Note, including, without limitation, those incurred: (i) during any
workout, attempted workout, and/or in connection with the rendering of legal
advice as to the Holder’s rights, remedies and obligations, (ii) collecting any
sums which become due to the Holder, (iii) defending or prosecuting any
proceeding or any counterclaim to any proceeding or appeal; or (iv) the
protection, preservation or enforcement of any rights or remedies of the Holder.
 
(12) Any waiver by the Holder of a breach of any provision of this Note shall
not operate as or be construed to be a waiver of any other breach of such
provision or of any breach of any other provision of this Note. The failure of
the Holder to insist upon strict adherence to any term of this Note on one or
more occasions shall not be considered a waiver or deprive that party of the
right thereafter to insist upon strict adherence to that term or any other term
of this Note. Any waiver must be in writing.
 
(13) If any provision of this Note is invalid, illegal or unenforceable, the
balance of this Note shall remain in effect, and if any provision is
inapplicable to any person or circumstance, it shall nevertheless remain
applicable to all other persons and circumstances. If it shall be found that any
interest or other amount deemed interest due hereunder shall violate applicable
laws governing usury, the applicable rate of interest due hereunder shall
automatically be lowered to equal the maximum permitted rate of interest. The
Company covenants (to the extent that it may lawfully do so) that it shall not
at any time insist upon, plead, or in any manner whatsoever claim or take the
benefit or advantage of, any stay, extension or usury law or other law which
would prohibit or forgive the Company from paying all or any portion of the
Principal of or interest on this Note as contemplated herein, wherever enacted,
now or at any time hereafter in force, or which may affect the covenants or the
performance of this indenture, and the Company (to the extent it may lawfully do
so) hereby expressly waives all benefits or advantage of any such law, and
covenants that it will not, by resort to any such law, hinder, delay or impeded
the execution of any power herein granted to the Holder, but will suffer and
permit the execution of every such as though no such law has been enacted.
 
(14) Whenever any payment or other obligation hereunder shall be due on a day
other than a Business Day, such payment shall be made on the next succeeding
Business Day.
 
(15) Assignment of this Note by the Company shall be prohibited without the
prior written consent of the Holder.  Prior to the Maturity Date, the Holder
shall not sell, transfer, negotiate or otherwise make any disposition of this
Note or any portion thereof without the prior written consent of the Company.
 
(16) THE PARTIES HEREBY KNOWINGLY, VOLUNTARILY AND INTENTIONALLY WAIVE THE RIGHT
ANY OF THEM MAY HAVE TO A TRIAL BY JURY IN RESPECT OF ANY LITIGATION BASED
HEREON OR ARISING OUT OF, UNDER OR IN CONNECTION WITH THIS NOTE OR ANY COURSE OF
CONDUCT, COURSE OF DEALING, STATEMENTS (WHETHER VERBAL OR WRITTEN) OR ACTIONS OF
ANY PARTY.  THIS PROVISION IS A MATERIAL INDUCEMENT FOR THE PARTIES’ ACCEPTANCE
OF THIS AGREEMENT.
 
 
 
 

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(17) CERTAIN DEFINITIONS   For purposes of this Note, the following terms shall
have the following meanings:
 
(a)  “Business Day” means any day except Saturday, Sunday and any day which
shall be a federal legal holiday in the United States or a day on which banking
institutions are authorized or required by law or other government action to
close.
 
(b)  “Closing Bid Price” means the price per share in the last reported trade of
the Common Stock on a Principal Market or on the exchange which the Common Stock
is then listed as quoted by Bloomberg L.P.
 
(c)  “Exchange Act” means the Securities Exchange Act of 1934, as amended.
 
(d) “Note Purchase Agreement” means the Note Purchase Agreement, dated _______,
2012, between the Company and the Holder.
 
(e) “Principal Market” means, the New York Stock Exchange, the Nasdaq Global
Select Market, the Nasdaq Global Market, the Nasdaq Capital Market, the OTC
Bulletin Board, or the NYSE Euronext, whichever is at the time the principal
trading exchange or market for the Common Stock.
 
(f)  “Trading Day” means a day on which the shares of Common Stock are quoted on
the OTCBB or quoted or traded on such Principal Market on which the shares of
Common Stock are then quoted or listed; provided, that in the event that the
shares of Common Stock are not listed or quoted, then Trading Day shall mean a
Business Day.
 
(g)  “VWAP” means, for any Trading Day, the daily volume weighted average price
of the Common Stock for such date on the Principal Market as reported by
Bloomberg L.P. (based on a Trading Day from 9:30 a.m. (New York City time) to
4:00 p.m. (New York City time)).
 
 [Signature Page Follows]
 

 
 

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IN WITNESS WHEREOF, the Company has caused this Secured Convertible Note to be
duly executed by a duly authorized officer as of the date set forth above.
 

 
COMPANY:
 
American Power Corp.
     
By:                                                               
 
Name:
 
Title:
   

 

 
 
 

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Schedule I
(Company Account Information)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Schedule II
(Holder Account Information)

 
 
 
 
 
 
 
 

 
 
 

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Exhibit A
Form of  Conversion Notice

 
In connection with the Senior Note (in order to Convert the Note)
 

TO:

The undersigned hereby irrevocably elects to convert
$                                        of the principal amount of Note No.
AMPW 1-__ into Shares of Common Stock of American Power Corp., according to the
conditions stated therein, as of the Conversion Date written below.
 
Conversion Date:
 
Conversion Amount to be
converted:
$                                                                                     
Conversion Price:
$                                                                                     
Number of shares of Common
Stock to be issued:
 
Amount of Note Unconverted:
$                                                                                     
       
Please issue the shares of Common Stock in the following name and to the
following address:
Issue to:
                                         
Authorized Signature:
 
Name:
 
Title:
 
Broker DTC Participant Code:
 
Account Number:
 

 

 

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