EXHIBIT 10.3

 

NEITHER THE ISSUANCE AND SALE OF THE SECURITIES REPRESENTED BY THIS CERTIFICATE
NOR THE SECURITIES INTO WHICH THESE SECURITIES ARE CONVERTIBLE HAVE BEEN
REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE STATE
SECURITIES LAWS. THE SECURITIES MAY NOT BE OFFERED FOR SALE, SOLD, TRANSFERRED
OR ASSIGNED (I) IN THE ABSENCE OF (A) AN EFFECTIVE REGISTRATION STATEMENT FOR
THE SECURITIES UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR (B) AN OPINION
OF COUNSEL (WHICH COUNSEL SHALL BE SELECTED BY THE HOLDER), IN A GENERALLY
ACCEPTABLE FORM, THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT OR (II) UNLESS
SOLD PURSUANT TO RULE 144 OR RULE 144A UNDER SAID ACT. NOTWITHSTANDING THE
FOREGOING, THE SECURITIES MAY BE PLEDGED IN CONNECTION WITH A BONA FIDE MARGIN
ACCOUNT OR OTHER LOAN OR FINANCING ARRANGEMENT SECURED BY THE SECURITIES.

 

Principal Amount: $___________ Issue Date: November 6, 2014

 

CONVERTIBLE PROMISSORY NOTE

 

FOR VALUE RECEIVED, AETHLON MEDICAL, INC., a Nevada corporation (hereinafter
called “Borrower”), hereby promises to pay to the order of , , Fax: (the
“Holder”), without demand, the sum of ______________________________
($_____________) (“Principal Amount”), with interest accruing thereon, on April
1, 2016 (the “Maturity Date”), if not sooner paid.

 

This Note has been entered into pursuant to the terms of a subscription
agreement between the Borrower, the Holder and the other signatories thereto
(“Other Holders”) dated at or about the date hereof (the “Subscription
Agreement”), who have been issued Notes pursuant to the Subscription Agreement
(“Other Notes”) and shall be governed by the terms of such Subscription
Agreement. Unless otherwise separately defined herein, all capitalized terms
used in this Note shall have the same meaning as is set forth in the
Subscription Agreement. The following terms shall apply to this Note:

 

ARTICLE I

 

GENERAL PROVISIONS

 

1.1     Interest Rate. Cash interest payable on this Note shall compound
annually and accrue at the annual rate of ten percent (10%) from the Issue Date
through the Maturity Date. Interest shall be payable in arrears on the Maturity
Date, accelerated or otherwise, when the principal and remaining accrued but
unpaid interest shall be due and payable, or sooner as described below. Interest
will be payable in cash or at the election of the Holder, may be converted to
Common Stock pursuant to Article II.

 

1.2     Payment Grace Period. The Borrower shall not have any grace period to
pay any monetary amounts due under this Note. During the pendency of an Event of
Default (as described in Article III), a default interest rate of eighteen
percent (18%) per annum shall be in effect.

 

1.3     Conversion Privileges. The Conversion Rights set forth in Article II
shall remain in full force and effect immediately from the date hereof and until
the Note is paid in full regardless of the occurrence of an Event of Default.
This Note shall be payable in full on the Maturity Date, unless previously
converted into Common Stock in accordance with Article II hereof.

 

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ARTICLE II

 

CONVERSION RIGHTS

 

The Holder shall have the right to convert the principal and any interest due
under this Note into Shares of the Borrower's Common Stock, $.001 par value per
share (“Common Stock”) as set forth below.

 

2.1.     Conversion into the Borrower's Common Stock.

 

(a)     The Holder shall have the right from and after the date of the issuance
of this Note and then at any time until this Note is fully paid, to convert any
outstanding and unpaid principal portion of this Note, and/or accrued interest,
at the election of the Holder (the date of giving of such notice of conversion
being a "Conversion Date") into fully paid and non-assessable shares of Common
Stock as such stock exists on the date of issuance of this Note, or any shares
of capital stock of Borrower into which such Common Stock shall hereafter be
changed or reclassified, at the conversion price as defined in Section 2.1(b)
hereof (the "Conversion Price"), determined as provided herein. Upon delivery to
the Borrower of a completed Notice of Conversion, a form of which is annexed
hereto as Exhibit A, Borrower shall issue and deliver to the Holder within three
(3) business days after the Conversion Date (such third day being the “Delivery
Date”) that number of shares of Common Stock for the portion of the Note
converted in accordance with the foregoing. At the election of the Holder, the
Borrower will deliver accrued but unpaid interest on the Note, if any, through
the Conversion Date directly to the Holder on or before the Delivery Date. The
number of shares of Common Stock to be issued upon each conversion of this Note
shall be determined by dividing that portion of the principal of the Note and
interest, if any, to be converted, by the Conversion Price.

 

(b)     Subject to adjustment as provided in Section 2.1(c) hereof, the
conversion price per share shall be equal to $0.112, subject to adjustment as
described herein.

 

(c)     The Conversion Price and number and kind of shares or other securities
to be issued upon conversion determined pursuant to Section 2.1(a), shall be
subject to adjustment from time to time upon the happening of certain events
while this conversion right remains outstanding, as follows:

 

A.     Merger, Sale of Assets, etc. If (A) the Borrower effects any merger or
consolidation of the Borrower with or into another entity, (B) the Borrower
effects any sale of all or substantially all of its assets in one or a series of
related transactions, (C) any tender offer or exchange offer (whether by the
Borrower or another entity) is completed pursuant to which holders of Common
Stock are permitted to tender or exchange their shares for other securities,
cash or property, (D) the Borrower consummates a stock purchase agreement or
other business combination (including, without limitation, a reorganization,
recapitalization, spin-off or scheme of arrangement) with one or more persons or
entities whereby such other persons or entities acquire more than the 50% of the
outstanding shares of Common Stock (not including any shares of Common Stock
held by such other persons or entities making or party to, or associated or
affiliated with the other persons or entities making or party to, such stock
purchase agreement or other business combination), (E) any "person" or "group"
(as these terms are used for purposes of Sections 13(d) and 14(d) of the 1934
Act) is or shall become the "beneficial owner" (as defined in Rule 13d-3 under
the 1934 Act), directly or indirectly, of 50% of the aggregate Common Stock of
the Borrower, or (F) the Borrower effects any reclassification of the Common
Stock or any compulsory share exchange pursuant to which the Common Stock is
effectively converted into or exchanged for other securities, cash or property
(in any such case, a "Fundamental Transaction"),this Note, as to the unpaid
principal portion thereof and accrued interest thereon, shall thereafter be
deemed to evidence the right to convert into such number and kind of shares or
other securities and property as would have been issuable or distributable on
account of such Fundamental Transaction, upon or with respect to the securities
subject to the conversion right immediately prior to such Fundamental
Transaction. The foregoing provision shall similarly apply to successive
Fundamental Transactions of a similar nature by any such successor or purchaser.
Without limiting the generality of the foregoing, the anti-dilution provisions
of this Section shall apply to such securities of such successor or purchaser
after any such Fundamental Transaction.

 

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B.     Reclassification, etc. If the Borrower at any time shall, by
reclassification or otherwise, change the Common Stock into the same or a
different number of securities of any class or classes that may be issued or
outstanding, this Note, as to the unpaid principal portion thereof and accrued
interest thereon, shall thereafter be deemed to evidence the right to purchase
an adjusted number of such securities and kind of securities as would have been
issuable as the result of such change with respect to the Common Stock
immediately prior to such reclassification or other change.

 

C.     Stock Splits, Combinations and Dividends. If the shares of Common Stock
are subdivided or combined into a greater or smaller number of shares of Common
Stock, or if a dividend is paid on the Common Stock in shares of Common Stock,
the Conversion Price shall be proportionately reduced in case of subdivision of
shares or stock dividend or proportionately increased in the case of combination
of shares, in each such case by the ratio which the total number of shares of
Common Stock outstanding immediately after such event bears to the total number
of shares of Common Stock outstanding immediately prior to such event.

 

(d)     Whenever the Conversion Price is adjusted pursuant to Section 2.1(c)
above, the Borrower shall promptly mail to the Holder a notice setting forth the
Conversion Price after such adjustment and setting forth a statement of the
facts requiring such adjustment.

 

(e)     During the period the conversion right exists, Borrower will reserve
from its authorized and unissued Common Stock not less than an amount of Common
Stock equal to 150% of the amount of shares of Common Stock issuable upon the
full conversion of this Note. Borrower represents that upon issuance, such
shares will be duly and validly issued, fully paid and non-assessable. Borrower
agrees that its issuance of this Note shall constitute full authority to its
officers, agents, and transfer agents who are charged with the duty of executing
and issuing stock certificates to execute and issue the necessary certificates
for shares of Common Stock upon the conversion of this Note.

 

2.2     Method of Conversion. This Note may be converted by the Holder in whole
or in part as described in Section 2.1(a) hereof and the Subscription Agreement.
Upon partial conversion of this Note, a new Note containing the same date and
provisions of this Note shall, at the request of the Holder, be issued by the
Borrower to the Holder for the principal balance of this Note and interest which
shall not have been converted or paid.

 

2.3.     Maximum Conversion. The Holder shall not be entitled to convert on a
Conversion Date that amount of the Note in connection with that number of shares
of Common Stock which would be in excess of the sum of (i) the number of shares
of Common Stock beneficially owned by the Holder and its affiliates on a
Conversion Date, (ii) any Common Stock issuable in connection with the
unconverted portion of the Note, and (iii) the number of shares of Common Stock
issuable upon the conversion of the Note with respect to which the determination
of this provision is being made on a Conversion Date, which would result in
beneficial ownership by the Holder and its affiliates of more than 4.99% of the
outstanding shares of Common Stock of the Borrower on such Conversion Date. For
the purposes of the provision to the immediately preceding sentence, beneficial
ownership shall be determined in accordance with Section 13(d) of the Securities
Exchange Act of 1934, as amended, and Regulation 13d-3 thereunder. Subject to
the foregoing, the Holder shall not be limited to aggregate conversions of
4.99%. The Holder shall have the authority and obligation to determine whether
the restriction contained in this Section 2.3 will limit any 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
Notes are convertible shall be the responsibility and obligation of the Holder.
The Holder may waive the conversion limitation described in this Section 2.3, in
whole or in part, upon and effective after 61 days prior written notice to the
Borrower to increase such percentage to up to 9.99%.

 

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2.4     Borrower’s Obligations. Upon the conversion of this Note or part
thereof, the Borrower shall, at its own cost and expense, take all necessary
action, including obtaining and delivering an opinion of counsel to assure that
the Borrower’s transfer agent shall issue stock certificates in the name of a
Holder (or its permitted nominee) or such other persons as designated by Holder
and in such denominations to be specified at conversion representing the number
of shares of Common Stock issuable upon such conversion. The Borrower warrants
that no instructions other than these instructions have been or will be given to
the Borrower’s transfer agent and that the certificates representing such shares
shall contain no legend other than the legend set forth in Section 4(h) of the
Subscription Agreement. If and when a Holder sells the Conversion Shares,
assuming (i) a registration statement including such Conversion Shares for
registration has been filed with the Commission, is effective and the
prospectus, as supplemented or amended, contained therein is current and (ii)
Holder or its agent confirms in writing to the transfer agent that Holder has
complied with the prospectus delivery requirements, the Borrower will reissue
the Conversion Shares without restrictive legend. In the event that the
Conversion Shares are sold in a manner that complies with an exemption from
registration, the Borrower will promptly instruct its counsel to issue to the
transfer agent an opinion permitting removal of the legend, provided that Holder
delivers reasonably requested representations in support of such opinion.

 

2.5     Late Delivery. The Borrower understands that a delay in the delivery of
the Conversion Shares in the form required pursuant to Section 2.4 hereof later
than the Delivery Date (as defined in the Subscription Agreement) could result
in economic loss to the Holder. As compensation to Holder for such loss, the
Borrower agrees to pay (as liquidated damages and not as a penalty) to Holder
for late issuance of Conversion Shares in the form required pursuant to this
Note upon Conversion of the Note, the amount of $100 per Trading Day (increasing
to $200 per Trading Day after ten (10) Trading Days) after the Delivery Date for
each $10,000 of Note principal amount and interest (and proportionately for
other amounts) being converted of the corresponding Conversion Shares which are
not timely delivered. The Borrower shall pay any payments incurred under this
Section upon demand. Furthermore, in addition to any other remedies which may be
available to the Holder, in the event that the Borrower fails for any reason to
effect delivery of the Conversion Shares on or before the Delivery Date, the
Holder will be entitled to revoke all or part of the relevant Notice of Holder
by delivery of a notice to such effect to the Borrower whereupon the Borrower
and Holder shall each be restored to their respective positions immediately
prior to the delivery of such notice, except that the damages payable in
connection with the Borrower’s default shall be payable through the date notice
of revocation or rescission is given to the Borrower.

 

2.6     Buy-In. In addition to any other rights available to Holders, if the
Borrower fails to deliver to a Holder Conversion Shares by the Delivery Date as
required pursuant to this Note and the Subscription Agreement and if after the
Delivery Date, Holder or a broker on Holder’s behalf purchases (in an open
market transaction or otherwise) shares of Common Stock to deliver in
satisfaction of a sale by Holder of the Common Stock which the Holder was
entitled to receive from the Company upon such conversion (a “Buy-In”), then the
Borrower shall pay in cash to each Holder (in addition to any remedies available
to or elected by the Holder) the amount by which (A) Holder’s total purchase
price (including brokerage commissions, if any) for the shares of Common Stock
so purchased exceeds (B) the aggregate principal and/or interest amount of the
Note for which such conversion request was not timely honored together with
interest thereon at a rate of 15% per annum, accruing until such amount and any
accrued interest thereon is paid in full (which amount shall be paid as
liquidated damages and not as a penalty). For example, if a Holder purchases
shares of Common Stock having a total purchase price of $11,000 to cover a
Buy-In with respect to an attempted conversion of $10,000 of Note principal
and/or interest, the Borrower shall be required to pay Holder $1,000 plus
interest. Holder shall provide the Borrower written notice and evidence
reasonably acceptable to the Borrower indicating the amounts payable to Holder
in respect of the Buy-In.

 

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ARTICLE III

 

EVENT OF DEFAULT

 

The occurrence of any of the following events of default ("Event of Default")
shall, at the option of the Holder hereof, make all sums of principal and
interest then remaining unpaid hereon and all other amounts payable hereunder
immediately due and payable, upon demand, without presentment, or grace period,
all of which hereby are expressly waived, except as set forth below:

 

3.1     Failure to Pay Principal or Interest. The Borrower fails to pay any
installment of principal, interest or other sum due under this Note when due.

 

3.2    Breach of Covenant. The Borrower breaches any material covenant or other
term or condition of the Subscription Agreement, Transaction Documents or this
Note in any material respect and such breach, if subject to cure, continues for
a period of ten (10) business days after written notice to the Borrower from the
Holder.

 

3.3     Breach of Representations and Warranties. Any material representation or
warranty of the Borrower made herein, in the Subscription Agreement, Transaction
Documents, or in any agreement, statement or certificate given in writing
pursuant hereto or in connection therewith shall be false or misleading in any
material respect as of the date made and the Closing Date.

 

3.4     Liquidation. Any dissolution, liquidation or winding up of Borrower or
any substantial portion of its business.

 

3.5     Cessation of Operations. Any cessation of operations by Borrower or
Borrower admits it is otherwise generally unable to pay its debts as such debts
become due.

 

3.6     Maintenance of Assets. The failure by Borrower to maintain any material
intellectual property rights, personal, real property or other assets which are
necessary to conduct its business (whether now or in the future).

 

3.7     Receiver or Trustee. The Borrower or any Subsidiary of Borrower shall
make an assignment for the benefit of creditors, or apply for or consent to the
appointment of a receiver or trustee for it or for a substantial part of its
property or business; or such a receiver or trustee shall otherwise be
appointed.

 

3.8     Judgments. Any money judgment, writ or similar final process shall be
entered or filed against Borrower or any of its property or other assets for
more than $100,000, unless stayed vacated or satisfied within forty-five (45)
days.

 

3.9     Bankruptcy. Bankruptcy, insolvency, reorganization or liquidation
proceedings or other proceedings or relief under any bankruptcy law or any law,
or the issuance of any notice in relation to such event, for the relief of
debtors shall be instituted by or against the Borrower or any Subsidiary of
Borrower.

 

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3.10     Delisting. Delisting of the Common Stock from any Principal Market;
failure to comply with the requirements for continued listing on a Principal
Market for a period of ten (10) consecutive trading days.

 

3.11     Non-Payment. Other than defaults disclosed on Schedule 5(l) to the
Subscription Agreement, a default by the Borrower under any one or more
obligations in an aggregate monetary amount in excess of $100,000 for more than
twenty (20) days after the due date, unless the Borrower is contesting the
validity of such obligation in good faith.

 

3.12     Stop Trade. An SEC or judicial stop trade order or Principal Market
trading suspension that lasts for five or more consecutive trading days.

 

3.13     Failure to Deliver Common Stock or Replacement Note. Borrower's
failures to timely deliver Common Stock to the Holder pursuant to and in the
form required by this Note and Sections 7 and 11 of the Subscription Agreement,
or, if required, a replacement Note.

 

3.14     Reservation Default. Failure by the Borrower to have reserved for
issuance upon conversion of the Note or upon exercise of the Warrants issued in
connection with the Subscription Agreement, the number of shares of Common Stock
as required in the Subscription Agreement, this Note and the Warrants.

 

3.15     Financial Statement Restatement. The restatement after the date hereof
of any financial statements filed by the Borrower with the Securities and
Exchange Commission for any date or period from two years prior to the Issue
Date of this Note and until this Note is no longer outstanding, if the result of
such restatement would, by comparison to the unrestated financial statements,
have constituted a Material Adverse Effect.

 

3.16     Other Note Default. The occurrence of any Event of Default under any
Other Note.

 

3.17     Event Described in Subscription Agreement. The occurrence of an Event
of Default as described in the Subscription Agreement that, if susceptible to
cure, is not cured during any designated cure period.

 

3.18     Cross Default. A default by the Borrower of a material term, covenant,
warranty or undertaking of any other agreement to which the Borrower and Holder
are parties, or the occurrence of a material event of default under any such
other agreement to which Borrower and Holder are parties which is not cured
after any required notice and/or cure period.

 

ARTICLE IV

 

MISCELLANEOUS

 

4.1     Failure or Indulgence Not Waiver. No failure or delay on the part of the
Holder hereof in the exercise of any power, right or privilege hereunder shall
operate as a waiver thereof, nor shall any single or partial exercise of any
such power, right or privilege preclude other or further exercise thereof or of
any other right, power or privilege. All rights and remedies existing hereunder
are cumulative to, and not exclusive of, any rights or remedies otherwise
available.

 

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4.2     Notices. All notices, demands, requests, consents, approvals, and other
communications required or permitted hereunder shall be in writing and, unless
otherwise specified herein, shall be (i) personally served, (ii) deposited in
the mail, registered or certified, return receipt requested, postage prepaid,
(iii) delivered by reputable air courier service with charges prepaid, or (iv)
transmitted by hand delivery, telegram, or facsimile, addressed as set forth
below or to such other address as such party shall have specified most recently
by written notice. Any notice or other communication required or permitted to be
given hereunder shall be deemed effective (a) upon hand delivery or delivery by
facsimile, with accurate confirmation generated by the transmitting facsimile
machine, at the address or number designated below (if delivered on a business
day during normal business hours where such notice is to be received), or the
first business day following such delivery (if delivered other than on a
business day during normal business hours where such notice is to be received)
or (b) on the first business day following the date of mailing by express
courier service, fully prepaid, addressed to such address, or upon actual
receipt of such mailing, whichever shall first occur. The addresses for such
communications shall be: (i) if to the Borrower to: Aethlon Medical, Inc., 9635
Granite Ridge Drive, Suite 100, San Diego, CA 92123, Attn: James A. Joyce, CEO,
facsimile: (858) 272-2738, with a copy by telecopier only to: Post Law Group,
PC., 5900 Wilshire Boulevard, Suite 620, Los Angeles, CA 90036, Attn: Jennifer
A. Post, Esq., facsimile: (800) 783–2983, and (ii) if to the Holder, to the
name, address and facsimile number set forth on the front page of this Note,
with a copy by fax only to Grushko & Mittman, P.C., 515 Rockaway Avenue, Valley
Stream, New York 11581, facsimile: (212) 697-3575.

 

4.3     Amendment Provision. The term “Note” and all reference thereto, as used
throughout this instrument, shall mean this instrument as originally executed,
or if later amended or supplemented, then as so amended or supplemented.

 

4.4     Assignability. This Note shall be binding upon the Borrower and its
successors and assigns, and shall inure to the benefit of the Holder and its
successors and assigns. The Borrower may not assign its obligations under this
Note.

 

4.5     Cost of Collection. If default is made in the payment of this Note,
Borrower shall pay the Holder hereof reasonable costs of collection, including
reasonable attorneys’ fees.

 

4.6     Governing Law. This Note shall be governed by and construed in
accordance with the laws of the State of New York without regard to conflicts of
laws principles that would result in the application of the substantive laws of
another jurisdiction. Any action brought by either party against the other
concerning the transactions contemplated by this Agreement must be brought only
in the civil or state courts of New York or in the federal courts located in the
State and county of New York. Both parties and the individual signing this
Agreement on behalf of the Borrower agree to submit to the jurisdiction of such
courts. The prevailing party shall be entitled to recover from the other party
its reasonable attorney's fees and costs. In the event that any provision of
this Note is invalid or unenforceable under any applicable statute or rule of
law, then such provision shall be deemed inoperative to the extent that it may
conflict therewith and shall be deemed modified to conform with such statute or
rule of law. Any such provision which may prove invalid or unenforceable under
any law shall not affect the validity or unenforceability of any other provision
of this Note. Nothing contained herein shall be deemed or operate to preclude
the Holder from bringing suit or taking other legal action against the Borrower
in any other jurisdiction to collect on the Borrower's obligations to Holder, to
realize on any collateral or any other security for such obligations, or to
enforce a judgment or other decision in favor of the Holder. This Note shall be
deemed an unconditional obligation of Borrower for the payment of money and,
without limitation to any other remedies of Holder, may be enforced against
Borrower by summary proceeding pursuant to New York Civil Procedure Law and
Rules Section 3213 or any similar rule or statute in the jurisdiction where
enforcement is sought. For purposes of such rule or statute, any other document
or agreement to which Holder and Borrower are parties or which Borrower
delivered to Holder, which may be convenient or necessary to determine Holder’s
rights hereunder or Borrower’s obligations to Holder are deemed a part of this
Note, whether or not such other document or agreement was delivered together
herewith or was executed apart from this Note.

 

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4.7     Maximum Payments. Nothing contained herein shall be deemed to establish
or require the payment of a rate of interest or other charges in excess of the
maximum rate permitted by applicable law. In the event that the rate of interest
required to be paid or other charges hereunder exceed the maximum rate permitted
by applicable law, any payments in excess of such maximum rate shall be credited
against amounts owed by the Borrower to the Holder and thus refunded to the
Borrower.

 

4.8     Non-Business Days. Whenever any payment or any action to be made shall
be due on a Saturday, Sunday or a public holiday under the laws of the State of
New York, such payment may be due or action shall be required on the next
succeeding business day and, for such payment, such next succeeding day shall be
included in the calculation of the amount of accrued interest payable on such
date.

 

4.9     Redemption. This Note may not be prepaid, redeemed or called without the
consent of the Holder.

 

4.10     Shareholder Status. The Holder shall not have rights as a shareholder
of the Borrower with respect to unconverted portions of this Note. However, the
Holder will have the rights of a shareholder of the Borrower with respect to the
Shares of Common Stock to be received after delivery by the Holder of a
Conversion Notice to the Borrower.

 

 

[THIS SPACE INTENTIONALLY LEFT BLANK]

 

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IN WITNESS WHEREOF, Borrower has caused this Note to be signed in its name by an
authorized officer as of the 6th day of November, 2014.

 

AETHLON MEDICAL, Inc.

 

 

By:_____________________________________

        Name:

        Title:

 

WITNESS:

 

 

 

______________________________________

 

 

 

 

 

 

 

 

 

 

 

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NOTICE OF CONVERSION

 

(To be executed by the Registered Holder in order to convert the Note)

 

 

The undersigned hereby elects to convert $_________ of the principal and
$_________ of the interest due on the Note issued by AETHLON MEDICAL, INC. on
November 6, 2014 into Shares of Common Stock of AETHLON MEDICAL, INC.(the
“Borrower”) according to the conditions set forth in such Note, as of the date
written below.

 

 

 

Date of Conversion:__________________________________________________________

 

 

Conversion Price:____________________________________________________________

 

 

Number of Shares of Common Stock Beneficially Owned on the Conversion Date: Less
than 5% of the outstanding Common Stock of AETHLON MEDICAL, INC.

 

 

Shares To Be Delivered:_______________________________________________________

 

 

Signature:__________________________________________________________________

 

 

Print Name:_________________________________________________________________

 

 

Address:___________________________________________________________________

 

___________________________________________________________________

 

 

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