--------------------------------------------------------------------------------

NONE OF THE SECURITIES TO WHICH THIS AGREEMENT RELATES HAVE BEEN REGISTERED
UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE "1933 ACT"), OR
ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED
OR SOLD IN THE UNITED STATES OR TO U.S. PERSONS (AS DEFINED HEREIN) EXCEPT
PURSUANT TO AN EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE
REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE
WITH APPLICABLE STATE AND/OR PROVINCIAL SECURITIES LAWS.

AGREEMENT

THIS AGREEMENT effective as of May 21, 2007.

AMONG:

ARKANOVA ENERGY CORPORATION
21 Waterway Avenue – Suite 300
The Woodlands, Texas 77381
(the "Company")

AND:

ARKANOVA ACQUISITION CORP.
21 Waterway Avenue – Suite 300
The Woodlands, Texas 77381
("Acquisition Corp.")

AND:

DAVID GRIFFIN
604 Cherry St
Helena, AR 72342-3306
(the "Subscriber")

WHEREAS:

A.           The Subscriber entered into a Oil and Gas Lease Acquisition and
Development Agreement dated July 24, 2006 (the "Development Agreement") with
Arkanova Energy, Inc. (the “Lessee”), a private Delaware company;

B.           Pursuant to the terms of the Development Agreement, the Subscriber
agreed to deliver to the Lessee leases (the “Leases”) of 100% of the mineral
rights in 50,000 acres, more or less, located in Phillips and Monroe Counties,
Arkansas as more particularly described in the Development Agreement, subject to
a royalty interest in favour of the lessors;

--------------------------------------------------------------------------------

2

C.           As at the date hereof, the Lessee has paid to the Subscriber, on
account of the lease bonus payments for the leasehold interests delivered by the
Subscriber and his affiliates and related parties, being David B. Griffin, his
wife, Roxanna S. Griffin, Griffin Family Investments Company Number One, and any
other entities in which David Griffin has at least a fifty percent ownership
interest (the “Related Parties”), a total of $8,498,205 (the "Paid to Date
Amount"), the receipt of which is hereby acknowledged by the Subscriber;

D.           The Paid to Date Amount has been allocated to the following leases,
for a balance due and owing of $1,372,873 (the "Lease Payment"), payable to the
Subscriber and the Related Parties upon delivery of evidence in form and
substance reasonably satisfactory to Lessee as more particularly described in
the Development Agreement:

Date of Lease

Name of Lessor

Acres Leased

Lease Bonus
Amount (DG
Interest) February 19, 2007 D.B. Griffin et al. 23,935.62 $7,180,684.50 November
17, 2006 Griffin/Howe et al. 16,567.52 $2,485,128 November 17, 2006
Griffin/Solomon et al. 1,368.44 $205,266.00       $9,871,078.50

E.           On March 1, 2007, the Lessee merged with and into Acquisition
Corp., with Acquisition Corp. carrying on as the surviving corporation (the
"Merger");

F.           By operation of law, and as of the effective date of the Merger,
all of the rights, assets and liabilities of the Lessee, including the rights
under the Development Agreement, were deemed vested in Acquisition Corp.; and

G.           The parties hereto seek to enter into this Agreement whereby,
following the payment by Acquisition Corp. to the Subscriber of an additional
sum of $1,000,000 on account of monies due to the Subscriber and the Related
Parties for the leasehold interests (the "Additional Payment"), the Subscriber
agrees to accept, at the election of the Company, shares of common stock in the
capital of the Company (each, a "Share") at a price of $1.25 per Share in full
and final settlement of the Lease Payment and any further payments due from
Acquisition Corp. for the Leases (each, an "Additional Lease Payment"), provided
that this Agreement shall not apply to (i) the acquisition of mineral interests
under the Area on Mutual Interest clause in the Agreement and (ii) shall only
apply to mineral rights owned by Subscriber and the Related Parties as of 5:00
P.M. Central Daylight time Monday, May 21, 2007.

--------------------------------------------------------------------------------

3

THEREFORE, in consideration of the mutual covenants and agreements herein
contained and other good and valuable consideration (the receipt and sufficiency
of which are hereby acknowledged), the parties covenant and agree as follows:

Issuance of Shares

1.                       Shares

1.1                     Acquisition Corp. agrees to immediately notify the
Company upon the payment of the Additional Payment (the "Notice of Payment").

1.2                     Upon receipt of the Notice of Payment by the Company,
and upon the election by the Company to pay the Lease Payment and any Additional
Lease Payment in Shares:

  (a)

the Company agrees to issue the Shares to the Subscriber on the basis of the
representations and warranties and subject to the terms and conditions set forth
herein;

        (b)

the Subscriber agrees to accept the Shares in full and final satisfaction of the
Lease Payment and/or any Additional Lease Payment, as applicable; and

        (c)

the Subscriber agrees to complete, sign and return to the Company as soon as
possible, on request by the Company, any documents, questionnaires, notices and
undertakings as may be required by regulatory authorities, the OTC Bulletin
Board, stock exchanges and applicable law.

2.                       Closing

2.1                     The closing of each issuance of the Shares shall occur
within fifteen (15) business days of the election, by the Company, to pay the
Lease Payment and/or any Additional Lease Payment, as applicable, in Shares (the
"Closing Date").

3.                       Acknowledgements of Subscriber

3.1                     The Subscriber acknowledges and agrees that:

  (a)

the Shares when issued will not be registered under the Securities Act of 1933,
as amended (the "1933 Act"), or under any state securities or "blue sky" laws of
any state of the United States, and are being offered only in a transaction not
involving any public offering within the meaning of the 1933 Act, and, unless so
registered, may not be offered or sold in the United States or to U.S. Persons
(as defined herein), except pursuant to an effective registration statement
under the 1933 Act, or pursuant to an exemption from, or in a transaction not
subject to, the registration requirements of the 1933 Act, and in each case only
in accordance with applicable state securities laws;

--------------------------------------------------------------------------------

4

  (b)

the Company will refuse to register any transfer of the Shares not made in
accordance with the provisions of Regulation S, pursuant to an effective
registration statement under the 1933 Act or pursuant to an available exemption
from, or in a transaction not subject to, the registration requirements of the
1933 Act;

        (c)

by completing the Questionnaire, the Subscriber is representing and warranting
that the Subscriber is an "accredited investor", as the term is defined in
Regulation D promulgated under the 1933 Act;

        (d)

the decision to execute this Agreement and accept the Shares agreed to be issued
hereunder has not been based upon any oral or written representation as to fact
or otherwise made by or on behalf of the Company and such decision is based
solely upon a review of publicly available information regarding the Company
available on the website of the United States Securities and Exchange Commission
(the "SEC") available at www.sec.gov (the "Company Information");

        (e)

the Subscriber has had a reasonable opportunity to review the Company
Information and to ask questions of and receive answers from the Company, and to
obtain additional information, to the extent possessed or obtainable without
unreasonable effort or expense, necessary to verify the accuracy of the
information contained in the Company Information, or any other document provided
to the Subscriber;

        (f)

the books and records of the Company were available upon reasonable notice for
inspection, subject to certain confidentiality restrictions, by the Subscriber
during reasonable business hours at its principal place of business and that all
documents, records and books pertaining to the issuance of the Shares have been
made available for inspection by the Subscriber

        (g)

the Company is entitled to rely on the representations and warranties and the
statements and answers of the Subscriber contained in this Agreement and the
Questionnaire and the Subscriber will hold harmless the Company from any loss or
damage it may suffer as a result of the Subscriber's failure to correctly
complete this Agreement and the Questionnaire;

        (h)

the Subscriber will indemnify and hold harmless the Company and, where
applicable, its respective directors, officers, employees, agents, advisors and
shareholders from and against any and all loss, liability, claim, damage and
expense whatsoever (including, but not limited to, any and all fees, costs and
expenses whatsoever reasonably incurred in investigating, preparing or defending
against any claim, lawsuit, administrative proceeding or investigation whether
commenced or threatened) arising out of or based upon any acknowledgment,
representation or warranty of the Subscriber contained herein, the Questionnaire
or in any other document furnished by the Subscriber to the Company in
connection herewith, being untrue in any material respect or any breach or
failure

--------------------------------------------------------------------------------

5

 

by the Subscriber to comply with any covenant or agreement made by the
Subscriber to the Company in connection therewith;

        (i)

the Subscriber has been advised to consult its own legal, tax and other advisors
with respect to the merits and risks of an investment in the Shares and with
respect to applicable resale restrictions and it is solely responsible (and the
Company is in any way responsible) for compliance with applicable resale
restrictions;

        (j)

the Shares are not listed on any stock exchange or automated dealer quotation
system and no representation has been made to the Subscriber that any of the
Shares will become listed on any stock exchange or automated dealer quotation
system, except that currently certain market makers make market in the shares of
the Company's common stock on the OTC Bulletin Board;

        (k)

neither the SEC nor any other securities commission or similar regulatory
authority has reviewed or passed on the merits of the Shares;

        (l)

no documents in connection with the issuance of the Shares have been reviewed by
the SEC or any state securities administrators; and

        (m)

there is no government or other insurance covering any of the Shares.

4.                       Representations, Warranties and Covenants of the
Subscriber

4.1                     The Subscriber hereby represents and warrants to and
covenants with the Company (which representations, warranties and covenants
shall survive the Closing Date) that:

  (a)

the Subscriber is an "accredited investor" as that term is defined in Regulation
D promulgated under the 1933 Act;

        (b)

the Subscriber has received and carefully read this Agreement;

        (c)

the Subscriber has the legal capacity and competence to enter into and execute
this Agreement and to take all actions required pursuant hereto and, if the
Subscriber is a corporation, it is duly incorporated and validly subsisting
under the laws of its jurisdiction of incorporation and all necessary approvals
by its directors, shareholders and others have been obtained to authorize
execution and performance of this Agreement on behalf of the Subscriber;

        (d)

the Subscriber (i) has adequate net worth and means of providing for its current
financial needs and possible personal contingencies, (ii) has no need for
liquidity in this investment, and (iii) is able to bear the economic risks of an
investment in the Shares for an indefinite period of time, and can afford the
complete loss of such investment;

--------------------------------------------------------------------------------

6

  (e)

all information contained in the Questionnaire is complete and accurate and may
be relied upon by the Company, and the Subscriber will notify the Company
immediately of any material change in any such information occurring prior to
the Closing Date;

        (f)

the Subscriber has the requisite knowledge and experience in financial and
business matters as to be capable of evaluating the merits and risks of the
investment in the Shares and the Company, and the Subscriber is providing
evidence of such knowledge and experience in these matters through the
information requested in the Questionnaire;

        (g)

the Subscriber understands and agrees that the Company and others will rely upon
the truth and accuracy of the acknowledgements, representations, warranties,
covenants and agreements contained in this Agreement and the Questionnaire and
agrees that if any of such acknowledgements, representations and agreements are
no longer accurate or have been breached, the Subscriber shall promptly notify
the Company;

        (h)

the Subscriber is aware that an investment in the Company is speculative and
involves certain risks, including the possible loss of the investment;

        (i)

the entering into of this Agreement and the transactions contemplated hereby do
not result in the violation of any of the terms and provisions of any law
applicable to, or, if applicable, the constating documents of, the Subscriber,
or of any agreement, written or oral, to which the Subscriber may be a party or
by which the Subscriber is or may be bound;

        (j)

the Subscriber has duly executed and delivered this Agreement and it constitutes
a valid and binding agreement of the Subscriber enforceable against the
Subscriber;

        (k)

the Subscriber is purchasing the Shares for its own account for investment
purposes only and not for the account of any other person and not for
distribution, assignment or resale to others, and no other person has a direct
or indirect beneficial interest is such Shares, and the Subscriber has not
subdivided his interest in the Shares with any other person;

        (l)

the Subscriber is not an underwriter of, or dealer in, the shares of the
Company's common stock, nor is the Subscriber participating, pursuant to a
contractual agreement or otherwise, in the distribution of the Shares;

        (m)

the Subscriber has made an independent examination and investigation of an
investment in the Shares and the Company and has either (i) depended on the
advice of its legal and financial advisors or (ii) has elected not to seek such
advice and has waived his right of obtaining advise from its legal and financial
advisors) and agrees that the Company will not be responsible in anyway
whatsoever for the Subscriber's decision to invest in the Shares and the
Company;

--------------------------------------------------------------------------------

7

  (n)

if the Subscriber is acquiring the Shares as a fiduciary or agent for one or
more investor accounts, the Subscriber has sole investment discretion with
respect to each such account, and the Subscriber has full power to make the
foregoing acknowledgements, representations and agreements on behalf of such
account;

          (o)

the Subscriber is not aware of any advertisement of any of the Shares and is not
acquiring the Shares as a result of any form of general solicitation or general
advertising including advertisements, articles, notices or other communications
published in any newspaper, magazine or similar media or broadcast over radio or
television, or any seminar or meeting whose attendees have been invited by
general solicitation or general advertising; and

          (p)

no person has made to the Subscriber any written or oral representations:

          (i)

that any person will resell or repurchase any of the Shares,

          (ii)

that any person will refund the consideration of any of the Shares,

          (iii)

as to the future price or value of any of the Shares, or

          (iv)

that any of the Shares will be listed and posted for trading on any stock
exchange or automated dealer quotation system or that application has been made
to list and post any of the Shares of the Company on any stock exchange or
automated dealer quotation system, except that currently certain market makers
make market in the shares of the Company's common stock on the OTC Bulletin
Board.

4.2                     In this Agreement, the term "U.S. Person" shall have the
meaning ascribed thereto in Regulation S promulgated under the 1933 Act and for
the purpose of the Agreement includes any person in the United States.

5.                       Acknowledgement and Waiver

5.1                     The Subscriber has acknowledged that the decision to
accept the Shares in full and final satisfaction of the Lease Payment was solely
made on the Company Information. The Subscriber hereby waives, to the fullest
extent permitted by law, any rights of withdrawal, rescission or compensation
for damages to which the Subscriber might be entitled in connection with the
distribution of any of the Shares.

6.                       Representations and Warranties will be Relied Upon by
the Company

6.1                     The Subscriber acknowledges that the acknowledgements,
representations and warranties contained herein are made by it with the
intention that they may be relied upon by the Company and its legal counsel in
determining the Subscriber's eligibility to acquire the Shares under applicable
securities legislation, or (if applicable) the eligibility of others on whose
behalf it is contracting hereunder to acquire the Shares under applicable
securities legislation. The

--------------------------------------------------------------------------------

8

Subscriber further agrees that by accepting delivery of the certificates
representing the Shares, it will be representing and warranting that the
acknowledgements representations and warranties contained herein are true and
correct as of the date hereof and will continue in full force and effect
notwithstanding any subsequent disposition by the Subscriber of such Shares.

7.                       Resale Restrictions

7.1                     The Subscriber acknowledges that any resale of the
Shares will be subject to resale restrictions contained in the securities
legislation applicable to the Subscriber or proposed transferee. The Subscriber
acknowledges that the Shares have not been registered under the 1933 Act or the
securities laws of any state of the United States. The Shares may not be offered
or sold in the United States unless registered in accordance with federal
securities laws and all applicable state securities laws or exemptions from such
registration requirements are available.

8.                       Legending and Registration of Subject Shares

8.1                     The Subscriber hereby acknowledges that upon the
issuance thereof, and until such time as the same is no longer required under
the applicable securities laws and regulations, the certificates representing
any of the Shares will bear a legend in substantially the following form:

> > > > NONE OF THE SECURITIES REPRESENTED HEREBY HAVE BEEN REGISTERED UNDER THE
> > > > UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE "1933 ACT"), OR
> > > > ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE
> > > > OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT
> > > > UNDER THE 1933 ACT OR PURSUANT TO AN EXEMPTION FROM, OR IN A TRANSACTION
> > > > NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN
> > > > EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.

8.2                     The Subscriber hereby acknowledges and agrees to the
Company making a notation on its records or giving instructions to the registrar
and transfer agent of the Company in order to implement the restrictions on
transfer set forth and described in this Agreement.

9.                       Costs

9.1                     The Subscriber acknowledges and agrees that all costs
and expenses incurred by the Subscriber (including any fees and disbursements of
any special counsel retained by the Subscriber) relating to the issuance of the
Shares shall be borne by the Subscriber.

--------------------------------------------------------------------------------

9

10.                     Governing Law

10.1                    This Agreement is governed by the laws of the State of
Texas and the federal laws of the United States applicable thereto. The
Subscriber, in its personal or corporate capacity and, if applicable, on behalf
of each beneficial purchaser for whom it is acting, irrevocably attorns to the
exclusive jurisdiction of the Courts of the State of Texas.

11.                     Survival

11.1                    This Agreement, including without limitation the
representations, warranties and covenants contained herein, shall survive and
continue in full force and effect and be binding upon the parties hereto
notwithstanding the completion of the issuance of the Shares by the Subscriber
pursuant hereto.

12.                     Assignment

12.1                    This Agreement is not transferable or assignable.

13.                     Severability

13.1                    The invalidity or unenforceability of any particular
provision of this Agreement shall not affect or limit the validity or
enforceability of the remaining provisions of this Agreement.

14.                     Entire Agreement

14.1                    Except as expressly provided in this Agreement and in
the agreements, instruments and other documents contemplated or provided for
herein, this Agreement contains the entire agreement between the parties with
respect to the issuance of the Shares and there are no other terms, conditions,
representations or warranties, whether expressed, implied, oral or written, by
statute or common law, by the Company or by anyone else.

15.                     Notices

15.1                    All notices and other communications hereunder shall be
in writing and shall be deemed to have been duly given if mailed or transmitted
by any standard form of telecommunication. Notices to the Subscriber and the
Company shall be directed to the address on the first page of this Agreement.

16.                     Counterparts and Electronic Means

16.1                    This Agreement may be executed in any number of
counterparts, each of which, when so executed and delivered, shall constitute an
original and all of which together shall constitute one instrument. Delivery of
an executed copy of this Agreement by electronic facsimile transmission or other
means of electronic communication capable of producing a printed copy will be
deemed to be execution and delivery of this Agreement as of the date hereinafter
set forth.

--------------------------------------------------------------------------------

10

17.                     Delivery and Registration Information

17.1                    Unless otherwise notified in writing by the Subscriber,
the certificates representing the Shares shall be registered and delivered to
the Subscriber as stated on the face page of this Agreement.

18.                     Currency

18.1                    Unless otherwise provided, all dollar amounts referred
to in this Agreement are in lawful money of the United States of America.

18.                     Further Acts

18.1                    The Subscriber covenants and agrees to and in favour of
the Company and Acquisition Corp. to promptly do all such further acts and
things as may be necessary to give effect to the intention of this Agreement and
the Development Agreement, and further agrees that in the event that the Leases
are owned by any affiliates of the Subscriber rather than by the Subscriber
directly, the Subscriber shall cause such affiliates to accept the issuance of
the Shares on account of the Lease Payment and provide the Company with a
certificate or certificates from such affiliates making the representations,
warranties, agreements, covenants and acknowledgements provided herein in favour
of the Company and Acquisition Corp.

 

IN WITNESS WHEREOF the parties hereto have duly executed this Agreement as of
the date set forth on page one of this Agreement.

 

ARKANOVA ENERGY CORPORATION

 

Per:   /s/ Arkanova Energy Corporation
          Authorized Signatory

 

ARKANOVA ACQUISITION CORP.

 

Per:    /s/ Arkanova Acquisition Corp.
           Authorized Signatory

--------------------------------------------------------------------------------

11

WITNESSED BY: )     )     )   Name )     )   Address ) /s/ David Griffin   )
DAVID GRIFFIN   )     )   Occupation )  

--------------------------------------------------------------------------------

SCHEDULE A

U.S. ACCREDITED INVESTOR QUESTIONNAIRE

All capitalized terms herein, unless otherwise defined, have the meanings
ascribed thereto in the Agreement.

This Questionnaire is for use by the Subscriber that has indicated an interest
in acquiring the Shares of ARKANOVA ENERGY CORPORATION (the "Company"). The
purpose of this Questionnaire is to assure the Company that the Subscriber will
meet the standards imposed by the 1933 Act and the appropriate exemptions of
applicable state securities laws. The Company will rely on the information
contained in this Questionnaire for the purposes of such determination. This
Questionnaire is not an offer of the Shares or any other securities of the
Company in any state other than those specifically authorized by the Company.

The Subscriber covenants, represents and warrants to the Company that it
satisfies one or more of the categories of "Accredited Investors", as defined by
Regulation D promulgated under the 1933 Act, as indicated below: (Please initial
in the space provide those categories, if any, of an "Accredited Investor" which
the Subscriber satisfies.)

_______ Category 1

An organization described in Section 501(c)(3) of the United States Internal
Revenue Code, a corporation, a Massachusetts or similar business trust or
partnership, not formed for the specific purpose of acquiring the Shares, with
total assets in excess of US $5,000,000.

   

_______ Category 2

A natural person whose individual net worth, or joint net worth with that
person's spouse, on the date of purchase exceeds US $1,000,000.

   

_______ Category 3

A natural person who had an individual income in excess of US $200,000 in each
of the two most recent years or joint income with that person's spouse in excess
of US $300,000 in each of those years and has a reasonable expectation of
reaching the same income level in the current year.

   

_______ Category 4

A "bank" as defined under Section (3)(a)(2) of the 1933 Act or savings and loan
association or other institution as defined in Section 3(a)(5)(A) of the 1933
Act acting in its individual or fiduciary capacity; a broker dealer registered
pursuant to Section 15 of the Securities Exchange Act of 1934 (United States);
an insurance company as defined in Section 2(13) of the 1933 Act; an investment
company registered under the Investment Company Act of 1940 (United States) or a
business development company as defined in Section 2(a)(48) of such Act; a Small
Business Investment Company licensed by the U.S. Small Business Administration
under Section 301(c) or (d) of the Small Business Investment Act of 1958 (United
States); a plan with total assets in excess of $5,000,000 established and
maintained by a state, a political subdivision thereof, or an agency or
instrumentality of a state or a political subdivision thereof, for the benefit

--------------------------------------------------------------------------------

- 2 -

of its employees; an employee benefit plan within the meaning of the Employee
Retirement Income Security Act of 1974 (United States) whose investment
decisions are made by a plan fiduciary, as defined in Section 3(21) of such Act,
which is either a bank, savings and loan association, insurance company or
registered investment adviser, or if the employee benefit plan has total assets
in excess of $5,000,000, or, if a self- directed plan, whose investment
decisions are made solely by persons that are accredited investors.

   

_______ Category 5

A private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940 (United States).

   

_______ Category 6

A director or executive officer of the Company.

   

_______ Category 7

A trust with total assets in excess of $5,000,000, not formed for the specific
purpose of acquiring the Shares, whose purchase is directed by a sophisticated
person as described in Rule 506(b)(2)(ii) under the 1933 Act.

   

_______ Category 8

An entity in which all of the equity owners satisfy the requirements of one or
more of the foregoing categories.

Note that prospective Subscribers claiming to satisfy one of the above
categories of Accredited Investor may be required to supply the Company with a
balance sheet, prior years' federal income tax returns or other appropriate
documentation to verify and substantiate the Subscriber's status as an
Accredited Investor.

If the Subscriber is an entity which initialled Category 8 in reliance upon the
Accredited Investor categories above, state the name, address, total personal
income from all sources for the previous calendar year, and the net worth
(exclusive of home, home furnishings and personal automobiles) for each equity
owner of the said entity:

--------------------------------------------------------------------------------

The Subscriber hereby certifies that the information contained in this
Questionnaire is complete and accurate and the Subscriber will notify the
Company promptly of any change in any such information. If this Questionnaire is
being completed on behalf of a corporation, partnership, trust or estate, the
person executing on behalf of the Subscriber represents that it has the
authority to execute and deliver this Questionnaire on behalf of such entity.

--------------------------------------------------------------------------------

- 3 -

IN WITNESS WHEREOF, the undersigned has executed this Questionnaire as of the
___ day of _______________, 200 .

If a Corporation, Partnership or Other Entity: If an Individual:            
Print of Type Name of Entity   Signature             Signature of Authorized
Signatory   Print or Type Name             Type of Entity Social Security/Tax
I.D. No. (if applicable)

--------------------------------------------------------------------------------