EXHIBIT 4.7


 


THE
SECURITIES REPRESENTED HEREBY HAVE BEEN ACQUIRED BY THE HOLDER NAMED HEREON FOR
ITS OWN ACCOUNT FOR INVESTMENT WITH NO INTENTION OF MAKING OR CAUSING TO BE
MADE ANY PUBLIC DISTRIBUTION OF ALL OR ANY PORTION THEREOF; AND SUCH SECURITIES
MAY NOT BE PLEDGED, SOLD OR IN ANY OTHER WAY TRANSFERRED IN THE ABSENCE OF AN
EFFECTIVE REGISTRATION STATEMENT FOR SUCH SECURITIES UNDER THE SECURITIES ACT
OF 1933, AS IN EFFECT AT THAT TIME OR AN OPINION OF COUNSEL REASONABLY
SATISFACTORY TO THE ISSUER THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT.


 


	
  LIGHTSPACE CORPORATION

  	
   

  
	
   

  	
   

  
	
  CONVERTIBLE
  PROMISSORY BRIDGE NOTE

  	
   

  
	
   

  	
   

  
	
   

  	
  November __, 2004

  
	
   

  	
   

  
	
  $__________

  	
   

  



 


FOR VALUE RECEIVED, the
undersigned Lightspace Corporation, a Delaware corporation (referred to herein
as “Borrower”), promises to pay to the order of _______________ (“Lender”), the
principal sum of __________________ ($___________), together with interest at
the rate set forth below on the outstanding principal balance of this note from
the date hereof until such outstanding principal is paid in full on the terms
and conditions set forth herein (this “Bridge Note”).  This Bridge Note is issued in connection with
the private placement of convertible promissory notes of like kind and tenor as
this Bridge Note (together with this Bridge Note, the “Bridge Notes”).


 


                All principal and interest under
the Bridge Notes shall become due and payable on the first  to occur of (i) May __, 2005 (the “Maturity Date”), or (ii) the
consummation of a public or private equity or debt offering or restructuring
transaction (through a merger, sale, recapitalization, extraordinary dividend,
stock repurchase, spin-off, joint venture or otherwise) pursuant to which the
Borrower receives gross proceeds of at least $2,500,000 (“Accelerated Maturity”).


 


                This Bridge Note shall have an
interest rate of 12% per annum, compounded monthly, to be paid in cash at the
sooner of the Maturity Date and Accelerated Maturity.


 


                Borrower shall have the right to
prepay this Bridge Note in full at any time, provided that a minimum of the
equivalent of three monthly interest payments have been paid by Borrower to
Lender. All prepayments shall be applied first to accrued interest and then to
principal.


 


Notwithstanding any other
provision hereof, interest paid or becoming due hereunder shall in no event
exceed the maximum rate permitted by applicable law.  All amounts due hereunder are payable in
lawful money of the United States of America to the Lender at the address above



 


 

















 


indicated.


 


This is the Bridge Note
referred to in the Subscription Agreement (“Subscription Agreement”), to be
executed by the Borrower and Lender as of the date hereof.  The terms and conditions of the Subscription
Agreement and all other documents and instruments delivered in connection
therewith, including, without limitation, the Warrants (collectively, the “Offering
Documents”) are incorporated by reference herein and made a part hereof.  The execution and delivery of the Offering
Documents shall not be a condition to the effectiveness of this Bridge Note
upon execution and delivery hereof by the Borrower.  The Borrower has taken all necessary action
to authorize the execution, delivery and performance of this Bridge Note. This
Bridge Note constitutes the legal, valid and binding obligations of the
Borrower, enforceable against it in accordance with its terms.  Notwithstanding anything contained herein or
in the Offering Documents, this Bridge Note shall be in default and Lender
shall have all rights and remedies available to it under the law, in the event
that Borrower shall not pay any amounts hereunder when due.  All capitalized terms not otherwise defined
herein shall have their respective meanings as set forth in the Subscription
Agreement.


 


Section 1. 
At any time from the date hereof through the date that this Bridge Note
is paid in full, Lender shall have the right, in its sole discretion, to
convert the principal balance of this Bridge Note then outstanding plus accrued
but unpaid interest, in whole or in part, into shares of Common Stock, par
value $.0001 per share (“Common Stock”) of the Borrower at a conversion price
(the “Conversion Price”) equal to the greater of: (i) $ per share; or, (ii) the
price per share of Common Stock or its convertible equivalent, in the next
subsequent stock sale transaction by the Borrower in which the total purchase
price exceeds $1 million, provided that the financial consideration to the
Borrower involved in that transaction is provided prior to 30 days before the
Maturity Date.


 


Lender may convert this
Bridge Note at the then applicable Conversion Price by the surrender of this
Bridge Note (properly endorsed) at the principal office of the Borrower, or at
such other agency or office of the Borrower in the United States of America as
the Borrower may designate by notice in writing to the Lender at the address of
Lender appearing herein. The Lender shall effect conversions by delivering to
the Borrower the form of Notice of Conversion attached hereto as Annex A
(a “Notice of Conversion”), specifying therein the principal amount of
Bridge Note to be converted and the date on which such conversion is to be
effected (a “Conversion Date”). 
If no Conversion Date is specified in a Notice of Conversion, the
Conversion Date shall be the date that such Notice of Conversion is provided
hereunder.  To effect conversions
hereunder, the Lender shall not be required to physically surrender Bridge
Notes to the Borrower unless the entire principal amount of this Bridge Note
plus all accrued and unpaid interest thereon has been so converted. Conversions
hereunder shall have the effect of lowering the outstanding principal amount of
this Bridge Note in an amount equal to the applicable conversion.  The Lender and the Borrower shall maintain
records showing the principal amount converted and the date of such
conversions.  The Lender and any
assignee, by acceptance of this Bridge Note, acknowledge and agree that, by
reason of the provisions of this paragraph, following conversion of a portion
of this Bridge Note, the unpaid and unconverted principal amount of this Bridge
Note may be less than the amount stated on the face hereof.  In the event of the conversion of all or a
portion of this Bridge Note, a certificate or 


 


 


2

















 


certificates for the securities so converted, as applicable, registered
in the name of the Lender, shall be delivered to the Lender as soon as
practicable after the receipt by Borrower of this Bridge Note and Lender’s
written request for conversion.


 


Section 2.               (a)           The Conversion Price and number and
kind of shares or other securities to be issued upon conversion determined
pursuant to Section 1, 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 the Borrower at any time shall consolidate
with or merge into or sell or convey all or substantially all its assets to any
other corporation, this Bridge Note, as to the unpaid principal portion thereof
and accrued interest thereon, shall thereafter be deemed to evidence the right
to purchase such number and kind of shares or other securities and property as
would have been issuable or distributable on account of such consolidation,
merger, sale or conveyance, upon or with respect to the securities subject to
the conversion or purchase right immediately prior to such consolidation,
merger, sale or conveyance.  The
foregoing provision shall similarly apply to successive 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 consolidation, merger,
sale or conveyance.


 


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 Bridge 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.            Dilutive
Issuance.   If the Borrower at any time,
shall issue, or be deemed to have issued, Additional Shares of Common Stock (as
hereinafter defined) without consideration or for consideration per share of
Common Stock (“New Share Consideration”) less than the consideration per share
of Antidilution-Protected Shares of 


 


 


3

















 


Common Stock (as hereinafter defined) (a “Triggering Issuance”) in
effect immediately prior to such issuance, then forthwith upon the occurrence
of any such event (the “Dilutive Event”) the Conversion Price shall be adjusted
proportionally so that the consideration per share of adjusted
Antidilution-Protected Shares of Common Stock (“Protected Share Consideration”)
is the lower of: the consideration per share of Antidilution-Protected Shares
of Common Stock at the time of signing of this Agreement; and, the
consideration per share at which point the Protected Share Consideration is
equal to the New Share Consideration.


 


As used herein:


 


“Additional Shares of
Common Stock” shall mean all shares of Common Stock issued or deemed to be
issued by the Borrower after the date hereof which represent a Triggering
Issuance.  If the Borrower issues any
Options or Convertible Securities (as hereinafter defined), the maximum number
of shares of Common Stock issuable thereunder, shall be deemed to be Additional
Shares of Common Stock issued as of the time of such issue, until such time as
such Options or Convertible Securities shall terminate or be exercised or
converted into Common Stock, upon which time the number of shares of Common
Stock actually thereupon issued shall be deemed to be Additional Shares of
Common Stock. The Borrower shall be deemed to have issued the maximum number of
shares of Common Stock potentially underlying any Options or Convertible
Securities.  Notwithstanding the
foregoing, no issuance or deemed issuance nor Common Stock or options or
warrants to purchase Common Stock issued to (i) officers, directors, or
employees of, or consultants to the Borrower pursuant to any compensation
agreement, plan or arrangement or the issuance of Common Stock upon the
exercise of any such options or warrants, provided such securities were issued
prior to the date hereof or pursuant to
a stock or option incentive plan approved by the board of directors of the
Borrower; (ii) upon conversion of existing convertible securities
outstanding as of the date hereof or this Bridge Note; (iii) upon exercise of
outstanding warrants existing as of the date hereof; (iv) in connection with a
business acquisition where the stockholders
of the Borrower prior to such acquisition own 50% or more of the Common Stock
of the Borrower following such acquisition, or (v) to an institution or
bank lender in connection with a loan transaction or equipment lease.


 


“Options” shall mean
rights, options or warrants to subscribe for, purchase or otherwise acquire
either Common Stock or Convertible Securities.


 


“Antidilution-Protected
Shares of Common Stock” shall mean all shares of Common Stock issued, issuable,
or deemed to be issued by the Borrower in connection with this Agreement.


 


“Convertible Securities”
shall mean any evidences of indebtedness, shares (other than Common Stock) or
other securities directly or indirectly convertible into or exchangeable for Common
Stock.


 


 


4

















 


 


With respect to Options
and Convertible Securities, “consideration” per share of Additional Shares of
Common Stock shall be determined by adding (x) the aggregate consideration
received upon issuance of the Options or Convertible Securities divided by the
number of shares receivable upon the exercise or conversion thereof and (y) the
minimum possible consideration per share received or to be received per share
upon the exercise, conversion or exchange of such Options or Convertible
Securities for shares of Common Stock.  “Consideration”
is defined throughout as net proceeds to the Borrower in the applicable
transaction.


 


                (b)           If the Borrower at any time while this Bridge Note is
outstanding, shall issue, or be deemed to have issued, Additional Shares of
Common Stock at a Dilutive Price, then forthwith upon the occurrence of the
Dilutive Event, and thereafter successively upon each such issue, the
Conversion Price shall be reduced as follows: (i) the number of shares of
Common Stock outstanding immediately prior to such issue shall be multiplied by
the Conversion Price in effect at the time of such issue and the product shall
be added to the aggregate consideration, if any, received by the Borrower upon
such issue of Additional Shares of Common Stock; and (ii) the sum so obtained
shall be divided by the number of shares of Common Stock outstanding
immediately after such issue.  The
resulting quotient shall be the adjusted Conversion Price.


 


(b)  In the event that this Bridge Note is not
converted or paid in full on or before the Maturity Date, the then applicable
Conversion Price shall be reduced by 4%.


 


(c)           In the event that this Bridge Note is
not converted or paid in full on or before the one month anniversary of the
Maturity Date, the then applicable Conversion Price, shall be reduced by 2% per
each month thereafter.


 


                (d)           Whenever the Conversion Price is
adjusted pursuant to any provision of Section 2 above, the Borrower shall
promptly mail to the Holder a notice setting forth the Conversion Price after
such adjustment and setting forth a brief 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 a sufficient number of shares to provide for the issuance of Common Stock
upon the full conversion of this Bridge Note, but not less than the amount of
shares of Common Stock required to be reserved pursuant to the Subscription
Agreement.  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 Bridge 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 Bridge Note.


 


Section 4. 
This Bridge Note and any of the rights granted hereunder are freely
transferable by the Lender, in its sole discretion, subject to federal and
state securities law restrictions, if any.


 


Section 5. 
The Borrower covenants that it will at all times reserve and keep
available out of  its authorized and
unissued shares of Common Stock solely for the purpose of issuance upon 


 


 


5

















 


conversion of this Bridge Note, each as herein provided, free from
preemptive rights or any other actual contingent purchase rights of persons
other than the Lender, not less than such number of shares of the Common Stock
as shall be issuable upon the conversion of the outstanding principal amount of
this Bridge Note.  The Borrower covenants
that all shares of Common Stock that shall be so issuable shall, upon issue, be
duly and validly authorized, issued and fully paid, nonassessable.  No consent of any other party and no consent,
license, approval or authorization of, or registration or declaration with, any
governmental authority, bureau or agency is required in connection with the
execution, delivery or performance by the Borrower, or the validity or
enforceability of this Bridge Note other than such as have been met or
obtained. The execution, delivery and performance of this Bridge Note and all
other agreements and instruments executed and delivered or to be executed and
delivered pursuant hereto or thereto or the securities issuable upon conversion
of this will not  violate any provision
of any existing law or regulation or any order or decree of any court,
regulatory body or administrative agency or the certificate of incorporation or
by-laws of the Borrower or any mortgage, indenture, contract or other agreement
to which the Borrower is a party or by which the Borrower or any property or assets
of the Borrower may be bound.


 


Section 6. 
Upon a conversion hereunder the Borrower shall not be required to issue
stock certificates representing fractions of shares of the Common Stock, and in
lieu of any fractional shares which would otherwise be issuable, the Borrower
shall issue the next highest whole number of shares of Common Stock.


 


Section 7. 
If (i) the Borrower shall declare a dividend (or any other distribution)
on the Common Stock; (ii) the Borrower shall declare a special nonrecurring cash
dividend on or a redemption of the Common Stock; (iii) the Borrower shall
authorize the granting to all holders of the Common Stock rights or warrants to
subscribe for or purchase any shares of capital stock of any class or of any
rights; (iv) the approval of any stockholders of the Borrower shall be required
in connection with any reclassification of the Common Stock, any consolidation
or merger to which the Borrower is a party, any sale or transfer of all or
substantially all of the assets of the Borrower, or any compulsory share
exchange whereby the Common Stock is converted into other securities, cash or
property; or (v) the Borrower shall authorize the voluntary or involuntary
dissolution, liquidation or winding up of the affairs of the Borrower; then, in
each case, the Borrower shall cause to be filed at each office or agency
maintained for the purpose of conversion of the Bridge Notes, and shall cause
to be mailed to the Lender at its last address as shall appear upon the Bridge
Note records of the Borrower, at least 20 calendar days prior to the applicable
record or effective date hereinafter specified, a notice stating (i) the date
on which a record is to be taken for the purpose of such dividend,
distribution, redemption, rights or warrants, or if a record is not to be
taken, the date as of which the holders of the Common Stock of record to be
entitled to such dividend, distribution, redemption, rights or warrants are to
be determined, or (ii) the date on which such reclassification, consolidation, merger,
sale, transfer, share exchange, dissolution, liquidation or winding up is
expected to become effective or close, and the date as of which it is expected
that holders of the Common Stock of record shall be entitled to exchange their
shares of the Common Stock for securities, cash or other property deliverable
upon such reclassification, consolidation, merger, sale, transfer, share
exchange, dissolution, liquidation or winding up, provided, that the
failure to mail such notice or any defect therein or in the mailing thereof
shall not affect the validity of the corporate 


 


 


6

















 


action required to be
specified in such notice.  The Lender is
entitled to convert this Bridge Note during the 20-day period commencing
the date of such notice to the effective date of the event triggering such
notice.


 


Section 8.   
The issuance of certificates for shares of the Common Stock or other
securities on conversion of this Bridge Note shall be made without charge to
the Lender for any documentary stamp or similar taxes that may be payable in
respect of the issue or delivery of such certificate, provided that the
Borrower shall not be required to pay any tax that may be payable in respect of
any transfer involved in the issuance and delivery of any such certificate upon
conversion in a name other than that of the Lender and the Borrower shall not
be required to issue or deliver such certificates unless or until the person or
persons requesting the issuance thereof shall have paid to the Borrower or its
designee the amount of such tax or shall have established to the satisfaction
of the Borrower that such tax has been paid.


 


Section 9. 
Any payment of principal or interest which remains unpaid for more than
five (5) days after such payment is due shall be subject to a penalty equal to
three percent (2%) per month of the amount of such payment then outstanding.


 


                Borrower agrees,
that in the event any amounts due and payable hereunder are collected by law or
through an attorney at law, to pay all costs of collection, including, without
limitation, reasonable attorney’s fees.


 


                Nothing herein
shall limit any right granted to Lender by any other instrument or document or
by law or equity.


 


The undersigned for
itself, and its respective successors and assigns, hereby waives presentment,
demand, notice, protest and all other demands and notices in connection with
the delivery, acceptance, performance or endorsement of this Bridge Note.


 


                Section 10.  Each of the following events, if occurring
while any of the principal or interest of this Bridge Note remains unpaid,
shall constitute an “Event of Default” hereunder:


 


(a)                                  The Borrower
shall fail to pay the principal or interest of this Bridge Note or any other
amounts payable to the Lender hereunder within three (3) days when due whether
at scheduled maturity, upon acceleration or otherwise.


 


(b)                                 Any representation or warranty made or
deemed to be made by the Borrower (or any of its officers, directors, employees
or agents) under or in connection with this Bridge Note or in any of the
Offering Documents shall prove to have been false or incorrect in any material
respect when made; provided, however, that such failure shall not
result in an Event of Default to the extent it is corrected by the Borrower
within a period of five (5) days after the date on which written notice
specifying such failure shall have been given to the Borrower.


 


 


7

















 


 


(c)                                  The Borrower
shall fail to observe or perform any other covenant, agreement or warranty
contained in, or otherwise commit any material breach of any of the Offering
Documents; provided, however, that such failure shall not result
in an Event of Default to the extent it is corrected by the Borrower within a period
of five (5) days after the date on which written notice specifying such failure
shall have been given to the Borrower.


 


(d)                                 Any money judgment, writ or similar
process shall be entered or filed against the Borrower or any subsidiary of the
Borrower or any of its property or other assets for more than $100,000, and
shall remain unvacated, unbonded or unstayed for a period of twenty (20) days;


(e)                                  The Borrower or any of its active
subsidiaries shall commence, or there shall be commenced against the Borrower
or any such active subsidiary a case under any applicable bankruptcy or
insolvency laws as now or hereafter in effect or any successor thereto, or the
Borrower commences any other proceeding under any reorganization, arrangement,
adjustment of debt, relief of debtors, dissolution, insolvency or liquidation
or similar law of any jurisdiction whether now or hereafter in effect relating
to the Borrower or any active subsidiary thereof or there is commenced against
the Borrower or any active subsidiary thereof any such bankruptcy, insolvency
or other proceeding which remains undismissed for a period of 60 days; or the
Borrower or any active subsidiary thereof is adjudicated insolvent or bankrupt;
or any order of relief or other order approving any such case or proceeding is
entered; or the Borrower or any active subsidiary thereof suffers any
appointment of any custodian or the like for it or any substantial part of its
property which continues undischarged or unstayed for a period of 60 days; or
the Borrower or any active subsidiary thereof makes a general assignment for
the benefit of creditors; or the Borrower shall fail to pay, or shall state
that it is unable to pay, or shall be unable to pay, its debts generally as
they become due; or the Borrower or any active subsidiary thereof shall call a
meeting of its creditors with a view to arranging a composition, adjustment or
restructuring of its debts; or the Borrower or any active subsidiary thereof
shall by any act or failure to act expressly indicate its consent to, approval
of or acquiescence in any of the foregoing; or any corporate or other action is
taken by the Borrower or any active subsidiary thereof for the purpose of
effecting any of the foregoing.


 


Immediately upon the
occurrence of an Event of Default, at Lender’s option, (i) the Maturity Date
shall be deemed to have occurred automatically and (ii) the entire principal
amount of this Bridge Note then outstanding, all other amounts payable by the
Borrower hereunder shall automatically become and be due and payable, without
presentment, demand, protest or any notice of any kind, all of which are hereby
expressly waived by the Borrower, anything herein to the contrary
notwithstanding.


 


Section 11. 
Any and all notices or other communications or deliveries to be provided
by the Lender hereunder, including, without limitation, any conversion notice,
shall be in writing and delivered personally, by facsimile, sent by a
nationally recognized overnight courier service or sent 


 


8

















 


by certified or registered mail, postage prepaid, addressed to the
Borrower, 125 CambridgePark Drive, Cambridge, MA 02140 or such other address or facsimile
number as the Borrower may specify for such purposes by notice to the Lender
delivered in accordance with this paragraph. 
Any and all notices or other communications or deliveries to be provided
by the Borrower hereunder shall be in writing and delivered personally, by
facsimile, sent by a nationally recognized overnight courier service or sent by
certified or registered mail, postage prepaid, addressed to each Lender at the
address of such Lender appearing on the books of the Borrower, or if no such
address appears, at the principal place of business of the Lender.  Any notice or other communication or
deliveries hereunder shall be deemed given and effective on the earliest of (i)
the date of transmission if delivered by hand or by telecopy that has been
confirmed as received by 5:00 P.M. on a business day, (ii) one business day after
being sent by nationally recognized overnight courier or received by telecopy
after 5:00 P.M. on any day, or (iii) five business days after being sent by certified or
registered mail, postage and charges prepaid, return receipt requested.


 


Section 12. 
Upon the occurrence and during the continuation of an Event of Default
and the declaration of the Maturity Date, the Lender shall have, in addition to
all other rights and remedies under this Agreement, this Bridge Note and
related documents, all other rights and remedies provided under  each applicable jurisdiction and other
applicable laws, which rights shall be cumulative.


 


Section 13. 
This Bridge Note and the provisions hereof are to be construed according
to and are governed by the laws of the State of New York, without regard to
principles of conflicts of laws thereof.


 


9

















 


IN WITNESS WHEREOF, the
Borrower has caused this Bridge Note to be duly executed by a duly authorized
officer as of the date first above indicated.


 


 


	
   

  	
   

  	
   

  	
   

  	
  Lightspace Corporation

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Name: 

  	
  Ken Lang

  
	
   

  	
   

  	
   

  	
   

  	
  Title:

  	
  Chief Executive Officer

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
								



 


 


10

















 


ANNEX A


 


NOTICE OF
CONVERSION


To Be
Executed by the Holder


in Order
to Convert Note


 


The undersigned Lender
hereby elects to convert $__________ currently outstanding and owed under the
Convertible Bridge Note issued to Lightspace Corporation at a Conversion Price
of $_______ (the “Bridge Note”) and to purchase ___________ shares of Common
Stock of Lightspace Corporation issuable upon conversion of such Bridge Note,
and requests that certificates for such securities shall be issued in the name
of:


 


 


	
   

  	
   

  
	
  (please print or type
  name and address)

  
	
   

  
	
   

  	
   

  
	
  (please insert social security
  or other identifying number)

  
	
   

  
	
  and be delivered as
  follows:

  
	
   

  
	
   

  
	
   

  	
   

  
	
  please print or type
  name and address)

  
	
   

  
	
   

  	
   

  
	
  (please insert social
  security or other identifying number)

  
	
   

  
	
  [NAME OF LENDER]

  
	
   

  
	
  By:

  	
   

  	
   

  
	
  Name:

  
	
  Title:

  
	
   

  
	
   

  
	
  Conversion Date:

  	
   

  	
   

  
	
   

  
					



 


11