Exhibit 10.2

THE SECURITIES REPRESENTED HEREBY HAVE BEEN OFFERED IN AN OFFSHORE TRANSACTION
TO A PERSON WHO IS NOT A U.S. PERSON PURSUANT TO REGULATION S UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”). NEITHER THE
SECURITIES REPRESENTED BY THIS DEBENTURE NOR THE SECURITIES ISSUABLE UPON
CONVERSION OF THIS DEBENTURE HAVE BEEN REGISTERED UNDER THE SECURITIES ACT, OR
ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED, MAY NOT BE OFFERED OR
SOLD, DIRECTLY OR INDIRECTLY, IN THE UNITED STATES (AS DEFINED HEREIN) OR TO
U.S. PERSONS EXCEPT IN ACCORDANCE WITH THE PROVISIONS OF REGULATION S UNDER THE
SECURITIES ACT, PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE
SECURITIES ACT, OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION
NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN EACH
CASE ONLY IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS. IN ADDITION,
HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY NOT BE CONDUCTED UNLESS IN
COMPLIANCE WITH THE SECURITIES ACT. “UNITED STATES” AND “U.S. PERSON” ARE AS
DEFINED BY REGULATION S UNDER THE SECURITIES ACT.

 

NO.1

US$600,000

SURGE ENTERPRISES, INC.

10% CONVERTIBLE DEBENTURE

Section 1.

General.

FOR VALUE RECEIVED, Surge Enterprises, Inc., a Nevada corporation
(the “Company”), hereby promises to pay to the order of Sovereign Services
Limited, or its registered assigns (the “Purchaser”), the principal sum of SIX
HUNDRED THOUSAND UNITED STATES DOLLARS (US$600,000), or such lesser amount as
shall then equal the outstanding principal amount hereof, together with interest
thereon at a rate equal to 10% (the “Interest Rate”) per annum, simple interest
computed on the basis of the actual number of days elapsed and a year of 360
days comprised of twelve 30 day months. Unless earlier converted in accordance
with Section 4, all unpaid principal, together with any then unpaid and accrued
interest and other amounts payable hereunder, shall be payable on demand
following the earlier of (i) November 1, 2008 (the “Maturity Date”) or (ii) when
such amounts become due and payable as a result of, and following, an Event of
Default in accordance with Section 2. The Company may repay all but not less
than all of the principle amount, or principle amount remaining, of this
Debenture, together with all accrued interest thereon, with thirty (30) days
written notice received by the Purchaser (the “Repayment Notice”). Upon receipt
of the Repayment Notice, the Purchaser shall have ten (10) days to convert all
but not less than all the principle amount, or principle amount remaining, of
this Debenture, together with all accrued interest thereon, by delivering the
Conversion Notice (as hereinafter defined), to the Company. Upon expiration of
ten (10) days following receipt of the Repayment Notice, the Purchaser shall
lose all right to convert the principle amount, or principle amount remaining,
of this Debenture,

 

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together with all accrued interest thereon. Except as otherwise provided herein,
all payments required to be made hereunder, if any, shall be made in such coin
or currency of the United States as at the time of payment shall be legal tender
therein for the payment of public and private debts. Interest shall accrue on
the unpaid balance of the principal amount of this Debenture (without any
compounding) from and including the date hereof to, but excluding, the date on
which the principal amount of this Debenture is paid in full (or converted in
accordance with Section 4 hereof) and shall be payable on the Maturity Date,
unless (i) the Company repays the principle amount, plus any accrued interest,
prior to the Maturity Date or (ii) the Purchaser converts the principle amount,
plus any accrued interest, prior to the Maturity Date. The payment of interest
on the Maturity Date shall be payable in Shares valued at the Conversion Price
each as defined in, and in accordance with, Section 4(a) hereof. No fractional
Shares shall be issued upon payment of interest under this Debenture. Upon
payment of interest of this Debenture at the Maturity Date or when such interest
becomes due and payable as a result of, and following, an Event of Default in
accordance with Section 2 hereof, the Company shall pay to the Purchaser the
amount of interest that is not paid by the issuance of the Shares in lieu of the
Company issuing any fractional Shares to the Purchaser.

Section 2.

Defaults.

The occurrence of any of the following shall constitute an “Event of Default”
under this Debenture:

(a)          the Company shall fail to pay (i) when due any principal or
interest payment hereof on the due date hereunder or (ii) any other payment
required under the terms of this Debenture on the date due;

(b)          the Company shall fail to observe or perform any other covenant,
obligation, condition or agreement contained in this Debenture and such failure
shall continue for ten (10) days after written notice thereof is delivered to
the Company;

(c)          any representation, warranty, certificate, or other statement
(financial or otherwise) made or furnished by or on behalf of the Company to the
Purchaser in writing in connection with this Debenture shall be false,
incorrect, incomplete or misleading in any material respect when made or
furnished;

(d)          the Company shall (i) apply for or consent to the appointment of a
receiver, trustee, liquidator or custodian of itself or of all or a substantial
part of its property, (ii) be unable, or admit in writing its inability, to pay
its debts generally as they mature, (iii) make a general assignment for the
benefit of its or any of its creditors, (iv) be dissolved or liquidated in full
or in part, (v) commence a voluntary case or other proceeding seeking
liquidation, reorganization or other relief with respect to itself or its debts
under any bankruptcy, insolvency or other similar law now or hereafter in effect
or consent to any such relief or to the appointment of or taking possession of
its property by any official in an involuntary case or other proceeding
commenced against it, or (vi) take any action for the purpose of effecting any
of the foregoing; or

(e)          proceedings for the appointment of a receiver, trustee, liquidator
or custodian of the Company or of all or a substantial part of the property
thereof, or an involuntary case or other proceedings seeking liquidation,
reorganization or other relief with respect to the Company or the debts thereof
under any bankruptcy, insolvency or other similar law now or hereafter in effect

 

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shall be commenced and an order for relief entered or such proceeding shall not
be dismissed or discharged within thirty (30) days of commencement.

Section 3.

Rights Of Purchaser Upon Default.

Upon the occurrence or existence of any Event of Default and following the
expiry of any applicable grace periods (other than an Event of Default referred
to in Section 2(e) hereof) and at any time thereafter during the continuance of
such Event of Default, the Purchaser may, by written notice to the Company,
declare all outstanding amounts payable by the Company hereunder to be
immediately due and payable without presentment, demand, protest or any other
notice of any kind, all of which are hereby expressly waived, anything contained
herein to the contrary notwithstanding. Upon the occurrence or existence of any
Event of Default described in Section 2(e) hereof, immediately and without
notice, all outstanding amounts payable by the Company hereunder shall
automatically become immediately due and payable, without presentment, demand,
protest or any other notice of any kind, all of which are hereby expressly
waived, anything contained herein to the contrary notwithstanding. In addition
to the foregoing remedies, upon the occurrence or existence of any Event of
Default, the Purchaser may exercise any other right, power or remedy permitted
to it by law, either by suit in equity or by action at law, or both.

Section 4.

Conversion.

(a)          Purchaser Conversion. At any time, and from time to time, the
Purchaser may, at its sole and exclusive option by delivering to the Company a
conversion notice in the form attached hereto as Annex A (the “Conversion
Notice”), convert all or any part of the principal (plus accrued but unpaid
interest thereon) outstanding under this Debenture into shares of common stock
in the capital of the Company (the “Shares”) at a conversion price per Share
equal to US$3.75 (the “Conversion Price”). Each Share converted under this
Debenture will be issued as fully paid and non-assessable. The Conversion Price
shall be subject to adjustment as provided in Section 5 hereof. The Purchaser
shall convert a minimum of US$10,000 of principal for any conversio n pursuant
to this Section 4(a).

(b)          Mechanics and Effect of Conversion. No fractional Shares shall be
issued upon conversion of this Debenture. Upon the conversion of the entire
principal outstanding under this Debenture (and any accrued interest thereon),
in lieu of the Company issuing any fractional Shares to the Purchaser, the
Company shall pay to the Purchaser the amount of outstanding principal (and any
accrued interest thereon) that is not so converted. The Purchaser shall not be
required to deliver the original Debenture in order to effect a conversion
thereunder. Execution and delivery of the Conversion Notice shall have the same
effect as cancellation of the original Debenture and issuance of a new Debenture
representing the remaining outstanding principal amount. Upon surrender of this
Debenture following one or more partia l conversions, the Company shall promptly
deliver to the Purchaser a new Debenture representing the remaining outstanding
principal amount. At its expense, the Company shall, as soon as practicable but
in no event more than ten (10) business days after conversion of this Debenture
pursuant to Section 4, issue and deliver to the Purchaser at such principal
office a certificate or certificates for the number of Shares to which the
Purchaser shall be entitled upon such conversion (bearing such legends as are
required by applicable state and federal securities laws in the opinion of
counsel to the Company), together with any other securities and property to
which the Purchaser is entitled upon such conversion under the terms of this
Debenture.

 

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(c)          Payment Of Expenses And Taxes On Conversion. The Company shall pay
all expenses, taxes and other charges payable in connection with the
preparation, execution, issuance and delivery of stock certificates and new
debentures pursuant to this Section 4, except that, in the event such stock
certificates or new debentures shall be registered in a name or names other than
the name of the holder of this Debenture, funds sufficient to pay all stock
transfer fees, which shall be payable upon the execution and delivery of such
stock certificate or certificates or new debentures, shall be paid by the holder
thereof to the Company at the time of delivering this Debenture to the Company
upon conversion.

Section 5.

Conversion Price Adjustments.

(a)          Adjustment For Stock Splits And Combinations. If the Company shall
at any time or from time to time after the date of original issuance of this
Debenture (the “Date of Original Issue”) effect a subdivision or reverse stock
split of the outstanding Common Stock, the Conversion Price in effect
immediately before a subdivision shall be proportionately decreased, and,
conversely, the Conversion Price in effect immediately before a reverse stock
split shall be proportionately increased. Any adjustment under this Section 5(a)
shall become effective at the close of business on the date the subdivision or
reverse stock split becomes effective.

(b)          Adjustment For Common Stock Dividends And Distributions. If the
Company at any time or from time to time after the Date of Original Issue
issues, or fixes a record date for the determination of holders of common stock
entitled to receive, a dividend or other distribution payable solely in
additional shares of common stock, the Conversion Price that is then in effect
shall be decreased as of the time of such issuance or, in the event such record
date is fixed, as of the close of business on such record date, by multiplying
the Conversion Price by a fraction (i) the numerator of which is the total
number of shares of common stock issued and outstanding immediately prior to the
time of such issuance or the close of business on such record date, and (ii) the
denominator of which is the sum of the tota l number of shares of common stock
issued and outstanding immediately prior to the time of such issuance or the
close of business on such record date plus the number of shares of common stock
issuable in payment of such dividend or distribution; provided, however, that if
such record date is fixed and such dividend is not fully paid or if such
distribution is not fully made on the date fixed therefor, the Conversion Price
shall be recomputed accordingly as of the close of business on such record date
and thereafter the Conversion Price shall be adjusted pursuant to this
Section 5(b) to reflect the actual payment of such dividend or distribution.

(c)          Adjustments For Other Dividends And Distributions. If the Company
at any time or from time to time after the Date of Original Issue issues, or
fixes a record date for the determination of holders of common stock entitled to
receive, a dividend or other distribution payable in securities of the Company
other than shares of common stock or in other property, in each such event
provision shall be made so that the Purchaser shall receive upon conversion
hereof, in addition to the number of shares of common stock receivable hereupon,
the amount of securities of the Company or other property which such Purchaser
would have received had this Debenture been converted into common stock on the
date of such event and had it thereafter, during the period from the date of
such event to and including the conversion date, retained such securities or
other property receivable by it as aforesaid during such period, subject to all
other adjustments called for during such period under this Section 5 with
respect to the rights of the Purchaser or with respect to such other securities
or other property by their terms. As used herein, the term “other property” does
not include cash.

 

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(d)          Adjustment For Reclassification, Exchange And Substitution. If at
any time or from time to time after the Date of Original Issue, the common stock
issuable upon the conversion of this Debenture is changed into the same or a
different number of shares of any class or series of stock, whether by
recapitalization, reclassification or otherwise (other than a subdivision or
reverse stock split or stock dividend or a reorganization, merger, consolidation
or sale of assets provided for elsewhere in this Section 5), then in any such
event the Purchaser shall have the right thereafter to convert this Debenture
into the kind and amount of stock and other securities and property receivable
upon such recapitalization, reclassification or other change by holders of the
number of shares of common stock into which th is Debenture could have been
converted immediately prior to such recapitalization, reclassification or
change, all subject to further adjustment as provided herein or with respect to
such other securities or property by the terms thereof.

(e)          Certificate Of Adjustment. In each case of an adjustment or
readjustment of the Conversion Price for the number of shares of common stock or
other securities issuable upon conversion of this Debenture, the Company, at its
own expense, shall cause its Secretary or Treasurer to compute such adjustment
or readjustment in accordance with the provisions hereof and prepare a
certificate showing such adjustment or readjustment, and shall mail such
certificate, by first class mail, postage prepaid, to the Purchaser at the
Purchaser’s address as shown in the Company’s books. The certificate shall set
forth such adjustment or readjustment, showing in detail the facts upon which
such adjustment or readjustment is based. No adjustment in the Conversion Price
shall be required to be made unless it would result in an increase or decrease
of at least one cent, but any adjustments not made because of this sentence
shall be carried forward and taken into account in any subsequent adjustment
otherwise required hereunder.

(f)           Notices Of Record Date. Upon (i) the establishment by the Company
of a record of the holders of any class of securities for the purpose of
determining the holders thereof who are entitled to receive any dividend or
other distribution, or (ii) any capital reorganization of the Company, any
reclassification or recapitalization of the capital stock of the Company, any
merger or consolidation of the Company with or into any other Company, or any
transfer of all or substantially all the assets of the Company to any other
person or any voluntary or involuntary dissolution, liquidation or winding up of
the Company, the Company shall mail to the Purchaser at least 20 days prior to
the record date specified therein a notice specifying (A) the date on which any
such record is to be taken for the purpose of such dividend or distribution and
a description of such dividend or distribution, (B) the date on which any such
reorganization, reclassification, transfer, consolidation, merger, dissolution,
liquidation or winding up is expected to become effective, and (C) the date, if
any, that is to be fixed as to when the holders of record of common stock (or
other securities), shall be entitled to exchange their shares of common stock
(or other securities), for securities or other property deliverable upon such
reorganization, reclassification transfer, consolidation, merger, dissolution,
liquidation or winding up.

Section 6.

Exchange or Replacement of Debentures.

(a)          The Purchaser may, at its option, in person or by duly authorized
attorney, surrender this Debenture for exchange, at the principal business
office of the Company, and receive in exchange therefore, a new Debenture in the
same principal amount as the unpaid principal amount of this Debenture and
bearing interest at the same annual rate as this Debenture,

 

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each such new Debenture to be dated as of the date of this Debenture and to be
in such principal amount as remains unpaid and payable to such person or
persons, or order, as the Purchaser may designate in writing; provided that any
such transfer of this Debenture complies with all applicable securities laws.

(b)          Upon receipt by the Company of evidence satisfactory to it of the
loss, theft, destruction, or mutilation of this Debenture and (in the case of
loss, theft or destruction) of an indemnity reasonably satisfactory to it, and
upon surrender and cancellation of this Debenture, if mutilated, the Company
will deliver a new Debenture of like tenor in lieu of this Debenture. Any
Debenture delivered in accordance with the provisions of this Section 6 shall be
dated as of the date of this Debenture.

Section 7.

Attorneys’ and Collection Fees.

Should the indebtedness evidenced by this Debenture or any part hereof be
collected at law or in equity or in bankruptcy, receivership or other court
proceedings, the Company agrees to pay, in addition to the principal and
interest due and payable hereon, all costs of collection, including reasonable
attorneys’ fees and expenses, incurred by the Purchaser in collecting or
enforcing this Debenture.

Section 8.

Waivers.

The Company hereby waives presentment, demand for payment, notice of dishonor,
notice of protest and all other notices or demands in connection with the
delivery, acceptance, performance or default of this Debenture. No delay by the
Purchaser in exercising any power or right hereunder shall operate as a waiver
of any power or right, nor shall any single or partial exercise of any power or
right preclude other or further exercise thereof, or the exercise thereof, or
the exercise of any other power or right hereunder or otherwise; and no waiver
whatsoever or modification of the terms hereof shall be valid unless set forth
in writing by the Purchaser and then only to the extent set forth therein.

Section 9.

Amendments.

Subject to the provisions of the Subscription Agreement dated November 1, 2006
(the “Subscription Agreement”), between the Company and the Purchaser, this
Debenture may not be amended without the express written consent of both the
Company and the Purchaser.

Section 10.

Governing Law.

This Debenture shall be deemed to be made under and shall be construed in
accordance with the laws of the Province of British Columbia without giving
effect to the principles of conflict of laws thereof.

Section 11.

Successors and Assigns.

The rights and obligations of the Company and the Purchaser under this Debenture
shall be binding upon and benefit the successors, assigns, heirs, administrators
and transferees of the parties. Notwithstanding the foregoing, neither this
Debenture nor any of the rights, interests or obligations hereunder may be
assigned, by operation of law or otherwise, in whole or in part, by the Company,
without the prior written consent of the Purchaser.

 

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Section 12.

Notices.

All notices, requests, demands and other communications to any party hereunder
shall be in writing (including facsimile or similar writing) and shall be given
to such party at its address or facsimile number set forth below or such other
address or facsimile number as such party may hereafter specify by notice to the
other parties listed below:

(a)

If to the Company:

Surge Enterprises, Inc.
307-1178 Hamilton Street
Vancouver, British Columbia
Canada V6B 2S2
Attention: Eric Boehnke
Telephone: 604-484-2405
Facsimile: 604-484-2403

 

 

 

 

with a copy to:

Clark Wilson LLP
Barristers and Solicitors
800-885 West Georgia Street
Vancouver, BC, Canada V6C 3H1
Attention: Cam McTavish
Facsimile: 604-687-6314

 

 

 

(b)

If to the Purchaser:

At the address set out on the signature page

 

 

Each such notice, request or other communication shall be effective (i) upon
receipt (provided, however, that notices received on a Saturday, Sunday or legal
holiday recognized in the Province of British Columbia, Canada, or after 5:00
p.m. on any other day will be deemed to have been received on the next business
day), if given by legible facsimile transmission with proof from sender of
confirmation of receipt, or (ii) if given by any other means, when delivered at
the address specified in this Section 12.

Section 13.

No Rights of Stockholders.

Except as otherwise provided herein, this Debenture shall not entitle the
Purchaser to any of the rights of a stockholder of the Company, including
without limitation, the right to vote, to receive dividends and other
distributions, or to receive any notice of, or to attend, meetings of
stockholders or any other proceedings of the Company, unless and to the extent
converted into shares of common stock in accordance with the terms hereof.

Section 14.

Entire Agreement.

This Debenture represents the entire agreement between the parties hereto with
respect to the subject matter hereof and there are no representations,
warranties or commitments, except as set forth herein. This Debenture may be
amended only by an instrument in writing executed by the parties hereto.

 

 

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Section 15.

Headings.

 

The headings used in this Debenture are used for convenience only and are not to
be considered in construing or interpreting this Debenture.

Section 16.

Electronic Means

Delivery of an executed copy of this Debenture 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 Debenture as of
the date hereinafter set forth.

Section 17.

Assignability

This Debenture shall be binding upon the Company and its successors and shall
enure to the benefit of the Purchaser and its successors. This Debenture is not
assignable by the Purchaser without the express written consent of the Company.

Section 18.

Currency

Unless expressly stated otherwise, all funds expressed in this Debenture are
stated in United States dollars.

Section 19.

Restrictions on Shares

The Shares issuable upon conversion of this Debenture may not be sold or
transferred unless (a) the Shares, first shall have been registered under the
Securities Act and applicable state securities laws, or (b) the Company shall
have been furnished with an opinion of legal counsel (in form, substance and
scope customary for opinions in such circumstances) to the effect that such sale
or transfer is exempt from registration requirements of the Securities Act, or
(c) the Shares, are sold under Rule 144 under the Securities Act. Except as
otherwise provided in the Subscription Agreement, each certificate for the
Shares issuable upon conversion of this Debenture that has not been so
registered and that has not been sold under an exemption that permits removal of
the legend, shall bear a legend substantially in the following form, as
appropriate:

“THE SECURITIES REPRESENTED HEREBY HAVE BEEN OFFERED IN AN OFFSHORE TRANSACTION
TO A PERSON WHO IS NOT A U.S. PERSON (AS DEFINED HEREIN) PURSUANT TO REGULATION
S UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES
ACT”). NONE OF THE SECURITIES REPRESENTED HEREBY HAVE BEEN REGISTERED UNDER THE
SECURITIES ACT, OR ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED,
MAY NOT BE OFFERED OR SOLD, DIRECTLY OR INDIRECTLY, IN THE UNITED STATES (AS
DEFINED HEREIN) OR TO U.S. PERSONS EXCEPT IN ACCORDANCE WITH THE PROVISIONS OF
REGULATION S UNDER THE SECURITIES ACT, PURSUANT TO AN EFFECTIVE REGISTRATION
STATEMENT UNDER THE SECURITIES ACT, OR PURSUANT TO AN AVAILABLE EXEMPTION FROM,
OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE
SECURITIES ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE STATE
SECURITIES LAWS. IN ADDITION, HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY
NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE SECURITIES ACT. “UNITED STATES”
AND “U.S. PERSON” ARE AS DEFINED BY REGULATION S UNDER THE SECURITIES ACT.”

 

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Upon the request of the Purchaser of a certificate representing any Shares
issuable upon conversion of this Debenture, the Company shall remove the
foregoing legend from the certificate and issue to the Purchaser a new
certificate free of any transfer legend, (a) if without an effective
registration statement with such request, the Company shall have received either
(i) an opinion of counsel, in form, substance and scope customary for opinions
in such circumstances, to the effect that any such legend may be removed from
such certificate, or (ii) satisfactory representations from the Purchaser that
the Purchaser is eligible to sell such security under Rule 144 or (b) a
registration statement under the Securities Act covering the resale of such
securities is in effect.

IN WITNESS WHEREOF, the Company has caused this Debenture to be duly executed by
its duly authorized officer as of the date indicated below.

Date: November 1, 2006

SURGE ENTERPRISES, INC.

 

By:

/s/ Eric Boehnke

Name: Eric Boehnke

Title: President, Secretary and Treasurer

 

Debenture No. 1

Amount:

US$600,000

Purchaser Name: Sovereign Services Limited

Address:

3E – Block 1, 25 Tai Hang Drive

 

Jardine’s Lookout

 

Hong Kong

Telephone:

(852) 2895-1736

Facsimile:

(852) 2895-1871

 

 

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ANNEX A

NOTICE OF CONVERSION

(To be executed by the Purchaser in order to Convert the Debenture)

 

TO:

SURGE ENTERPRISES, INC.

 

The undersigned hereby irrevocably elects to convert US$_______________________
of the principal amount of the Debenture effective as of November 1, 2006
between the Company and Sovereign Services Limited, into shares of common stock
in the capital of the Company according to the conditions stated therein, as of
the conversion date written below. All capitalized terms used herein shall have
the meanings assigned thereto in the Debenture.

 

Conversion Date:

____________________________________________________

Applicable Conversion Price:

US$_________________________________________________

Amount to be converted:

US$_______________________________________________

Number of Shares of common stock to be issued:

____________________________________________________

Amount of Debenture unconverted:

Principal: US$

Please issue the Shares of common stock in the following name and to the
following address:

____________________________________________________

____________________________________________________

 

____________________________________________________

 

 

Signature of the Holder:

____________________________________________________

Name:

____________________________________________________

Address:

____________________________________________________

 

____________________________________________________

 

 

Phone Number:

____________________________________________________

 

 

 

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