Exhibit 10.3

FORM OF
SECURITY AGREEMENT

          THIS SECURITY AGREEMENT (this “Agreement”) is made and entered into as
of the date set forth on the signature page hereto, by and between VENDINGDATA
CORPORATION, a Nevada corporation (“Debtor”), and the parties listed on the
signature pages hereto (each a “Secured Party” and together the “Secured
Parties”).

WITNESSETH:

          WHEREAS, Debtor is conducting a private placement (the
“Private Placement”) of units exempt from the registration requirements of the
Securities Act of 1933, as amended (the “Securities Act”), where said units
shall consist of a 10% senior convertible promissory notes in increments of
Fifty Thousand Dollars ($50,000) (the “Units”);

          WHEREAS, Debtor proposes to sell through the Private Placement a
minimum of Six Million Two Hundred Fifty Thousand Dollars ($6,250,000) and a
maximum of Ten Million Dollars ($10,000,000) in Units;

          WHEREAS, pursuant to the Private Placement, Debtor proposes to borrow
money from Secured Parties in the original principal amount of up to Ten Million
Dollars ($10,000,000) pursuant to the promissory notes issued as part of the
Private Placement (the “Notes”);

          WHEREAS, Debtor has agreed to secure its obligations arising under the
Notes, including all debts, obligations, liabilities, interest, fees, charges
and expenses arising under the Notes (the “Obligations”), by entering into this
Agreement with Secured Parties;

          WHEREAS, this Agreement replaces in its entirety that certain Security
Agreement entered into with respect to the Company’s 9% Senior Secured Notes
that closed on September 17, 2004;

          NOW, THEREFORE, for and in consideration of the promises and mutual
covenants, agreements, understandings, undertakings, representations, warranties
and promises, and subject to the conditions hereinafter set forth, and intending
to be legally bound thereby, the parties do hereby covenant and agree that the
recitals set forth above are true and accurate and are hereby incorporated in
and made a part of this Agreement, and further covenant and agree as follows:

1. SECURITY INTEREST

          Subject to the terms and conditions of this Agreement, Debtor hereby
grants to Secured Parties, as a group, a first priority security interest in all
of Debtor’s right, title and interest in all property and interests of Debtor,
tangible or intangible, whether now or hereafter existing, wherever located
(collectively, the “Collateral”), including all:

          1.1. Accounts, including but not limited to, all accounts, all rights
of Debtor to payment for goods sold or leased or for services rendered, all
accounts receivable of Debtor; all obligations owing to Debtor evidenced by an
instrument or chattel paper; all obligations owing to Debtor of any kind or
nature, including all writings, if any, evidencing the same, including all
instruments, drafts, acceptances and chattel paper; any and all proceeds of any
of the foregoing. Further included within the term “Accounts” are all right,
title and interest of Debtor in and any security and liens with respect to any
Account, and all Accounts, Documents and Contract Rights of Debtor as defined in
the Uniform Commercial Code as enacted in the State of Nevada (the “Uniform
Commercial Code”); and

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          1.2. Investment Property, including all of Debtor’s investment
property (as defined in the Uniform Commercial Code) and all of Debtor’s other
securities (whether certificated or uncertificated), security entitlements,
financial assets, securities accounts, commodity contracts, and commodity
accounts (as each such term is defined in the Uniform Commercial Code),
including all substitutions and additions thereto, all dividends, distributions
and sums distributable or payable from, upon or in respect of such property, and
all rights and privileges incident to such property; and

          1.3. Instruments and Chattel Paper, including all instruments and
chattel paper as defined in the Uniform Commercial Code and all proceeds
thereof; and

          1.4. General Intangibles, including but not limited to, all general
intangibles as defined in the Uniform Commercial Code and all proceeds thereof,
including without limitation, any and all rights of Debtor to any refund of any
tax assessed against Debtor or paid by Debtor, loss carry-back tax refunds,
insurance premium rebates, unearned premiums, insurance proceeds, chooses in
action, names, trade names, goodwill, trade secrets, computer programs, computer
records, data, computer software, customer lists, patents, patent rights, patent
applications, patents pending, patent licenses or assignments, development ideas
and concepts, licenses, permits, franchises, literary rights, rights to
performance, trademarks, trademark applications, trademark rights, logos,
intellectual property, copyrights, proprietary or other processes, drawings,
designs, diagrams, plans, reports, charts, catalogs, manuals, research,
literature, proposals and other reproductions on paper or otherwise, of any and
all concepts or ideas, whether or not related to the business or operations of
Debtor; and

          1.5. Equipment as defined in the Uniform Commercial Code, including
but not limited to, all equipment, vehicles, machinery, tools, furniture,
fixtures, trade fixtures, parts, all tangible personal property utilized in the
conduct of Debtor’s business and all additions, accessions, substitutions,
components, and replacements thereto, therefor and thereof and all proceeds
thereof; and

          1.6. Inventory as defined in the Uniform Commercial Code, including
without limitation, all raw materials and other materials and supplies,
work-in-progress and finished goods and any products made or processed therefrom
and all substances, if any, commingled therewith or added thereto; and

          1.7. All products and proceeds of the above, including insurance
proceeds.

2. OBLIGATIONS SECURED

          2.1. Obligations Secured. The security interest granted hereby secures
payment and performance of the Obligations under the Notes on a pari passu
basis.

          2.2. Seniority. The payment of the Notes is senior to all other
obligations of Debtor whether now existing or hereinafter incurred except for:
(1) existing asset-based borrowings and lines of credit from commercial or
financial institutions, including Madison Leasing or Central Leasing in the
aggregate amount of $2,834,689 as of December 31, 2004; and (2) indebtedness
approved by the prior written consent from each Secured Party.

          2.3. Collateral Agent. No later than February 10, 2005, Debtor shall
identify a financial institution to serve as the authorized representative for
the Secured Parties (the “Collateral Agent”) and establish the rights and
obligations of the Collateral Agent. Debtor shall provide written notice of the
proposed Collateral Agent and the proposed agreement governing the rights and
obligations of the Collateral Agent to all Secured Parties (the “Collateral
Agent Agreement”). Upon the approval of the Collateral Agent and the terms and
conditions of the Collateral Agent Agreement by the holders of a majority of the
then outstanding and unpaid principal on the Notes issued under the Private
Placement, Debtor shall enter into the Collateral Agent Agreement, at which time
the Collateral Agent Agreement shall be binding upon all Secured Parties. Each
Secured Party agrees to not unreasonably withhold its consent to the Collateral
Agent Agreement. Debtor shall pay for all costs and expenses related to the
identification of the Collateral Agent, the preparation of the Collateral Agent
Agreement and the retention of the Collateral Agent.

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            2.3.1. In the event that Debtor fails to identify a prospective
Collateral Agent by February 10, 2005, the interest rate on the Notes shall be
increased by two percent (2%) to twelve percent (12%) per annum until such time
that Debtor has cured such failure.

3. DEBTOR’S REPRESENTATIONS AND WARRANTIES

          Debtor represents and warrants that:

          3.1. Authorization. The execution, delivery and performance of this
Agreement and the Notes are within Debtor’s corporate powers, and are not in
contravention of law nor of the terms of Debtor’s Articles of Incorporation or
Bylaws, as amended, nor of any indenture, agreement or undertaking to which
Debtor is a party or by which it is bound.

          3.2. Place of Business. Debtor’s principal place of business is
located at the address provided on the signature page of this Agreement, and
Debtor keeps its records concerning inventory, accounts, contract rights and
other property at that location.

          3.3. Title to Collateral. With the exception of liens created
hereunder and liens related to certain existing asset-based borrowings and lines
of credit from Madison Leasing or Central Leasing, Debtor owns all of its
personal property and has good, clear and marketable title thereto, free and
clear of all liens and encumbrances.

          3.4. Collateral and Perfection. Neither Debtor nor, to the best of
Debtor’s knowledge, any affiliate (as such term is used in Rule 405 under the
Securities Act of 1933, as amended (“Affiliates”)) have performed any acts which
might prevent the Collateral Agent from enforcing any of the terms of this
Agreement or which would limit the Collateral Agent in any such enforcement. No
collateral is in the possession of any person (other than Debtor) asserting any
claim thereto or security interest therein. The security interests created
hereunder constitute valid first priority security interests under the Uniform
Commercial Code securing the Obligations to the extent that a security interest
may be created in the Collateral.

4. GENERAL OBLIGATIONS OF DEBTOR

          4.1. Financing Statements. Debtor agrees to execute one or more
financing statements, to pay the cost of filing the same in all public offices
wherever filing is required by applicable law to perfect a security interest or
is deemed by Secured Parties to be necessary or desirable and to execute such
other documents as Secured Parties shall reasonably request.

          4.2. Insurance. Debtor agrees to keep or cause to be kept all the
Collateral insured with coverages in amounts not less than usually carried by
one engaged in a like business.

          4.3. Inspection. Debtor will keep accurate and complete records of the
Collateral and provide Secured Parties or any of their agents with the right to:
(1) inspect the Collateral wherever located; (2) visit Debtor’s place or places
of business; and (3) audit, check and make extracts from any copies of books,
records, journals, orders, receipts and correspondence that relate to the
Collateral or to the general financial condition of Debtor or any Affiliate. The
rights granted to Secured Parties shall be subject to prior written notice of
five (5) business days, shall be at reasonable intervals and shall not adversely
affect, disrupt or hinder Debtor’s operations.

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          4.4. Negative Pledge. Debtor will not assign any accounts or other
Collateral to any person other than Secured Parties, nor create or permit to be
created any lien, encumbrance or security interest of any kind on any of its
accounts, contract rights or inventory other than for the benefit of Secured
Parties, nor grant or permit to be granted any corporate guaranty other than for
the benefit of Secured Parties, except (a) indebtedness for borrowed money which
is expressly subordinated to the Obligations in all respects, on such terms and
conditions as have been approved by the holders of Notes representing majority
of the then outstanding and unpaid principal on all of the then issued and
outstanding Notes and (b) purchase price liens.

          4.5. Existence; Perfection. Debtor will maintain its corporate
existence in good standing and comply with all laws and regulations of the
United States or any state or political subdivision thereof, or of any
governmental authority which may have jurisdiction over it or its business.
Debtor will not change its name, identity or corporate structure in any manner
unless it shall have given Secured Parties prior written notice thereof and
delivered an opinion of counsel satisfactory to Secured Parties with respect
thereto. Debtor will not establish or change the location of its chief executive
office or its chief place of business or except in the ordinary course of
business, the locations where it keeps or holds any Collateral or records
relating thereto or in any event change the location of any Collateral if such
change would cause the security interests hereunder to lapse or cease to be
perfected.

          4.6. Taxes. Debtor will pay all real and personal property taxes,
assessments and charges as well as all franchise, income, unemployment, old age
benefit, withholding, sales and other taxes assessed against it, or payable by
it at such times and in such manner as to prevent any penalty from accruing or
any lien or charge from attaching to its property, and will furnish Secured
Parties upon request, receipts or other evidence that deposits or payments have
been made.

          4.7. Sales. Debtor will not sell or dispose of any of its assets,
including the Collateral, except in the ordinary and usual course of its
business.

          4.8. Repair. Debtor will maintain its equipment and property in good
repair and working order.

          4.9. Observation Rights. Debtor shall provide to a representative of
the holders of more than fifty-one percent (51%) of the outstanding principal on
the Notes, where such representation shall be in writing, the right to receive
written notice of each regularly scheduled meeting of Debtor’s Board of
Directors (including any meetings of committees thereof) as far in advance as
such notice is required to be delivered to the Directors and the right to attend
as observers of all meetings of the Board of Directors (including any meetings
of committees thereof); provided, further, in the case of telephonic meetings
conducted in accordance with Debtor’s bylaws and applicable law, the
representatives will be given notice and the opportunity to listen to such
telephonic meetings. The notice and observation rights provided for in this
Section 4.9 are subject to the execution by the representative of a
non-disclosure agreement in the form requested by Debtor and shall terminate
when less than fifteen percent (15%) of the original outstanding principal on
the Notes issued under the Private Placement remains outstanding.

          4.10. Continuing Representations. The warranties and representations
made by Debtor in this Agreement are continuing. In the event that any
obligation, representation or warranty is no longer true or correct, Debtor will
immediately notify Secured Parties in writing.

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5. DEFAULT

          Debtor shall be in default under this Agreement and under any other
agreement with Secured Parties upon the happening of any of the following events
or conditions:

          5.1. Failure of Debtor to pay when due any Obligation, whether by
maturity, acceleration or otherwise, where such failure shall have remained
uncured for a period of two (2) business days following the due date of such
payment;

          5.2. A breach by Debtor of any representation, warranty, covenant or
agreement set forth in this Agreement, the Notes or the Subscription Agreements
(“Subscription Agreements”) by and between the Company and any Secured Party
with respect to the issuance of the Notes in the Private Placement, where such
breach shall have remained uncured for a period of fifteen (15) days following
the receipt of written notice of such breach;

          5.3. Material loss or theft, substantial damage or destruction or
unauthorized sale or encumbrance of any material portion of the Collateral in
excess of reasonably expected recoveries under insurance policies, or the making
of any levy on, or seizure or attachment of a material portion of the
Collateral;

          5.4. The occurrence of a default under any of the Notes;

          5.5. The bankruptcy of Debtor or any subsidiary of Debtor, which
means: (1) the filing of any petition or answer by Debtor seeking to adjudicate
Debtor as bankrupt or insolvent, or seeking for Debtor any liquidation, winding
up, reorganization, arrangement, adjustment, protection, relief, or composition
of Debtor or Debtor’s debts under any law relating to bankruptcy, insolvency or
reorganization or relief of debtors, or seeking, consenting to, or acquiescing
in the entry of an order for relief or the appointment of a receiver, trustee,
custodian or other similar official for Debtor or for any substantial part of
Debtor’s property; or (2) corporate action taken by Debtor to authorize any of
the actions set forth above;

          5.6. The involuntary bankruptcy of Debtor or any subsidiary of Debtor,
which means, without the consent or acquiescence of Debtor, the entering of an
order for relief or approving a petition for relief or reorganization or any
other petition seeking any reorganization, arrangement, composition,
readjustment, liquidation, dissolution or other similar relief under any present
or future bankruptcy, insolvency or similar statute, law or regulation, or the
filing of any such petition against such person, which petition shall not be
dismissed within ninety (90) days, or without the consent or acquiescence of
Debtor, the entering of an order appointing a trustee, custodian, receiver or
liquidator of Debtor or of all or any substantial part of the property of
Debtor, which order shall not be dismissed within ninety (90) days;

          5.7. The appointment of a receiver, trustee, custodian or other
similar official for any substantial part of Debtor’s property;

          5.8. Failure of Debtor to pay when due any obligation, whether by
maturity, acceleration or otherwise, in an amount in excess of One Hundred
Thousand Dollars ($100,000), where such failure is not cured within any
applicable grace period or waived;

          5.9. Failure to return proceeds to Secured Parties pursuant to Section
4.2 of the Subscription Agreements; or

          5.10. The incurrence of indebtedness through loans, lines of credit
and other forms of indebtedness (which for purposes of this Section 5.10 shall
include lease financing arrangements for equipment) in an amount is excess of
Fifteen Million Dollars ($15,000,000).

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6. RIGHTS of SECURED PARTIES UPON DEFAULT

          Through the Collateral Agent, as appointed pursuant to this Agreement,
Secured Parties shall upon the occurrence of a default hereunder and at any time
thereafter, without presentment, demand, notice, protest or advertisement of any
kind have the following rights in addition to all other rights hereunder:

          6.1. Acceleration. Subject to the terms of the Notes, the Collateral
Agent may make all Obligations under this or any other agreement with Debtor
immediately due and payable without presentment, demand, protest, hearing or
notice of any kind and may exercise the rights of a secured party under law or
under the terms of this or any other agreement with Debtor.

          6.2. Possession. On behalf of all Secured Parties, the Collateral
Agent may: (1) enter and take possession of all Equipment, Inventory and other
Collateral and the premises on which they are located; (2) operate and use
Debtor’s equipment, whether or not Collateral hereunder; (3) complete work in
process; (4) apply as Debtor’s attorney-in-fact for domestic or foreign patents
or other intellectual property rights with respect to inventions; (5) seek
registration or assignment, foreign and domestic, of any trademarks, trade
names, styles, logos or copyrights; and (6) sell, lease or license the
Collateral to third persons or associations without being liable to Debtor on
account of any losses, damage or depreciation that may occur as a result thereof
so long as the Collateral Agent shall act reasonably and in good faith. The
Collateral Agent shall give Debtor and all Secured Parties at least thirty (30)
days’ notice by hand delivery at or by United States certified mail, postage
prepaid (in which event notice shall be deemed to have been given when so
delivered), to the address specified herein, of the time and place of any public
or private sale or other disposition unless the Collateral is perishable,
threatens to decline speedily in value, or is the type customarily sold in a
recognized market. Upon such sale, a Secured Party may become the purchaser of
the whole or any part of the Collateral, discharged from all claims and free
from any right of redemption. In case of any such sale by the Collateral Agent
of all or any of said Collateral on credit or for future delivery, property so
sold may be retained by the Collateral Agent until the selling price is paid by
the purchaser. The Collateral Agent shall incur no liability in case of the
failure of the purchaser to take up and pay for the property so sold. In case of
any such failure, the said property may again be sold.

          6.3. Power of Attorney and Notification. At Debtor’s expense and
subject to the rights of the Secured Parties, the Collateral Agent may
communicate with account debtors in order to verify with them to its
satisfaction the existence, amount and terms of any accounts or contract rights
and also notify account debtors that Collateral has been assigned for the
benefit of the Secured Parties and that payments shall be made directly to the
Collateral Agent. Upon request of the Collateral Agent, Debtor will so notify
such account debtors and will indicate on all billings to such account debtors
that their accounts must be paid to the Collateral Agent. Debtor does hereby
appoint the Collateral Agent and its agents as Debtor’s attorney-in-fact: to,
upon an event of default hereunder, collect, compromise, endorse, sell or
otherwise deal with the Collateral or proceeds thereof in its own name or in the
name of Debtor; to endorse the name of Debtor upon any Note, checks, drafts,
money orders, or other instruments, documents, receipts or Collateral that may
come into its possession and to apply the same in full or part payment of any
amounts owing to Secured Parties; to sign and endorse the name of Debtor upon
any documents, instruments, drafts against account debtors, assignments,
verifications and notices in connection with Accounts, and any instrument or
document relating thereto or to Debtor’s rights therein; and to give written
notice to any office and officials of the United States Post Office to effect
such change or changes of address that all mail addressed to Debtor may be
delivered directly to the Collateral Agent. Debtor hereby grants to its said
attorney-in-fact full power to do any and all things necessary to be done in and
about the premises as fully and effectually as Debtor might or could do, and
hereby ratifies all that its attorney-in-fact shall lawfully do or cause to be
done by virtue hereof. This power of attorney is coupled with an interest and is
irrevocable for the term of this Agreement for all transactions hereunder and
thereafter as long as Debtor may be indebted to Secured Parties.

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          6.4. Application of Proceeds. Any and all proceeds of any Collateral
realized or obtained by Collateral Agent upon exercise of the rights and
remedies hereunder, shall be applied as follows:

            6.4.1. Toward the payment of any and all costs and expenses, fees
and commission and taxes of such sale, collection or other realization incurred
by the Collateral Agent or any Secured Party;

            6.4.2. With respect to any surplus remaining after application of
proceeds as provided in Section 6.4.1, toward the payment of the Obligations on
a pro rata basis, and any costs, fees or expenses incurred in connection with
the administration, collection or enforcement thereof, including, without
limitation, reasonable attorney’s fees and other professionals’ out of pocket
costs and fees, until payment and satisfaction in full thereof; and

            6.4.3. With respect to any surplus remaining after application of
proceeds as provided in Section 6.4.2 above, shall be paid to Debtor, or its
successors or assigns, or to whomsoever may be lawfully entitled to receive the
same.

7. DEBTOR’S OBLIGATION TO PAY EXPENSES

          In the event the Collateral Agent is the prevailing party in any
action brought to enforced the rights of Secured Parties hereunder, Debtor shall
pay to the Collateral Agent on demand any and all reasonable expenses
(including, but not limited to, a collection charge on all accounts collected,
all reasonable attorney’s fees and expenses, and all other expenses of like or
unlike nature) that may be incurred or paid by the Collateral Agent or Secured
Parties to obtain or enforce payment of any account against the account debtor,
Debtor or any guarantor or surety of or in the prosecution or defense of any
action or concerning any matter growing out of or connected with the subject
matter of this Agreement, the Obligations, such Collateral or the rights or
interests of Secured Parties therein or thereto. All such expenses may be added
to the principal amount of any indebtedness owed by Debtor to Secured Parties
and shall constitute part of such Obligations secured hereby.

8. WAIVER; AMENDMENT

          Debtor waives demand, presentment, protest, notice of nonpayment and
all other notices. No delay or omission by the Collateral Agent in exercising
any rights shall operate as a waiver of such right or any other right. Waiver on
any one occasion shall not be construed as a bar to or waiver of any right or
remedy on any future occasion. The rights and remedies of Secured Parties,
whether evidenced hereby or by any other agreement, instrument or paper, shall
be cumulative and may be exercised singularly or concurrently. Unless otherwise
provided in this Agreement or in the Notes, any waiver or amendment of any
provisions of this Agreement shall be in writing, executed and delivered by the
Company and by Secured Party or Secured Parties holding Notes representing not
less than a majority of the then outstanding principal of all of the Notes then
issued and outstanding.

9. FURTHER ASSURANCES

          Debtor, at its own expense, shall do, make, execute and deliver all
such additional and further acts, deeds, assurances, documents, instruments and
certificates as the Collateral Agent may reasonably require, including, without
limitation: (1) executing, delivering and filing financial statements and
continuation statements under the Uniform Commercial Code as applicable in any
relevant jurisdiction; (2) obtaining governmental and other third party consents
and approvals; and (3) obtaining waivers from mortgagees and landlords.

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10. COUNTERPART EXECUTION

          This Agreement may be executed in any number of counterparts with the
same effect as if Debtor and all of the Secured Parties had signed the same
document. All counterparts shall be construed together and shall constitute one
agreement.

11. CHOICE OF LAW

          THIS AGREEMENT AND THE NOTES SHALL BE GOVERNED BY AND CONSTRUED AND
ENFORCED IN ACCORDANCE WITH THE LAWS (AND NOT THE LAW OF CONFLICTS) OF THE STATE
OF NEVADA. THE PARTIES HERETO HEREBY SUBMIT TO THE EXCLUSIVE JURISDICTION OF THE
COURTS LOCATED IN CLARK COUNTY, NEVADA WITH RESPECT TO ANY DISPUTE ARISING UNDER
THIS AGREEMENT AND THE TRANSACTIONS CONTEMPLATED HEREBY.

12. WAIVER OF JURY TRIAL

          DEBTOR HEREBY WAIVES TRIAL BY JURY IN ANY JUDICIAL PROCEEDING
INVOLVING, DIRECTLY OR INDIRECTLY, ANY MATTER (WHETHER SOUNDING IN TORT,
CONTRACT OR OTHERWISE) IN ANY WAY ARISING OUT OF, RELATED TO, OR CONNECTED WTTH
THIS AGREEMENT OR THE NOTES OR THE RELATIONSHIP ESTABLISHED HEREUNDER,
THEREUNDER.

[Signature page follows]

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          IN WITNESS WHEREOF, the parties hereto have signed this Agreement as
of the _______ day of ________________ 2005.

“DEBTOR” ADDRESS

VENDINGDATA CORPORATION,
        a Nevada corporation 6830 Spencer Street
Las Vegas, Nevada 89119

By:  ___________________________________________
        Steven J. Blad
Its:  President and Chief Executive Officer TELEPHONE:   702-733-7195
FACSIMILE:     702-733-7197

“SECURED PARTIES” ADDRESS

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

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“SECURED PARTIES” ADDRESS

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

_____________________________________
(Insert Name) ______________________________________________
______________________________________________

By:  ___________________________________________
        ___________________________________________
Its:  ___________________________________________ TELEPHONE:   ____-____-____
FACSIMILE:     ____-____-____

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