exv10w16



 





EXHIBIT 10.16




TASER INTERNATIONAL, INC.

2004 OUTSIDE DIRECTOR STOCK OPTION PLAN




(AS ADOPTED BY THE BOARD OF DIRECTORS ON JANUARY 30, 2004 AND APPROVED BY THE STOCKHOLDERS AT THE APRIL 29,

2004 ANNUAL MEETING OF STOCKHOLDERS)




(AMENDED BY THE BOARD OF DIRECTORS IN MARCH, 2006)



1. Purposes of the Plan. The purposes of this 2004 Outside Director Stock Option Plan are to
attract and retain the best available personnel for service as Outside Directors (as defined
herein) of the Company, to provide additional incentive to the outside directors of the Company to
serve as Directors, and to encourage their continued service on the Board.




     All options granted hereunder shall be nonstatutory stock options.



     2. Definitions. As used herein, the following definitions shall apply:



          (a) “Board” means the Board of Directors of the Company.




          (b) “Code” means the Internal Revenue Code of 1986, as amended.




          (c) “Common Stock” means the Common Stock of the Company.




          (d) “Company” means TASER International, Inc., a Delaware corporation.




          (e) “Director” means a member of the Board.




          (f) “Employee” means any person, including officers and Directors, employed by the Company or
any Parent or Subsidiary of the Company. The payment of a Director’s fee by the Company shall not
be sufficient in and of itself to constitute “employment” by the Company.




          (g) “Exchange Act” means the Securities Exchange Act of 1934, as amended.




          (h) “Fair Market Value” means, as of any date, the value of Common Stock determined as
follows:




               (i) If the Common Stock is listed on any established stock exchange or a national market
system, including without limitation the NASDAQ National Market or The NASDAQ SmallCap Market of
The NASDAQ Stock Market, its Fair Market Value shall be the closing sales price for such stock (or
the closing bid, if no sales were reported) as quoted on such exchange or system for the last
market trading day prior to the time of determination, as reported in The Wall Street Journal or
such other source as the Administrator deems reliable;




               (ii) If the Common Stock is regularly quoted by a recognized securities dealer but selling
prices are not reported, the Fair Market Value of a Share of Common Stock shall be the mean between
the high bid and low asked prices for the Common Stock on the date of determination, as reported in
The Wall Street Journal or such other source as the Board deems reliable, or;




               (iii) In the absence of an established market for the Common Stock, the Fair Market Value
thereof shall be determined in good faith by the Board.




          (i) “Inside Director” means a Director who is an Employee.




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          (j) “Option” means a stock option granted pursuant to the Plan.




          (k) “Optioned Stock” means the Common Stock subject to an Option.




          (l) “Optionee” means a Director who holds an Option.




          (m) “Outside Director” means a Director who is (i) not an Employee and (ii) not a partner nor
a member of any venture capital firm or institutional investor which owns securities of the Company
having more than five percent (5%) of the total voting power of the Company.




          (n) “Parent” means a “parent corporation,” whether now or hereafter existing, as defined in
Section 424(e) of the Code.




          (o) “Plan” means this 2004 Director Stock Option Plan.




          (p) “Share” means a share of the Common Stock, as adjusted in accordance with Section 10 of
the Plan.




          (q) “Subsidiary” means a “subsidiary corporation,” whether now or hereafter existing, as
defined in Section 424(f) of the Internal Revenue Code of 1986.




     3. Stock Subject to the Plan. Subject to the provisions of Section 10 of the Plan, the
maximum aggregate number of Shares which may be optioned and sold under the Plan is 200,000 Shares
of Common Stock (the “Pool”) on a post January 26, 2004 stock split basis. The Shares may be
authorized, but unissued, or reacquired Common Stock.



     If an Option expires or becomes unexercisable without having been exercised in full, the
unpurchased Shares which were subject thereto shall become available for future grant or sale under
the Plan (unless the Plan has terminated). Shares that have actually been issued under the Plan
shall not be returned to the Plan and shall not become available for future distribution under the
Plan.



     4. Administration and Grants of Options under the Plan.



          (a) Procedure for Grants. All grants of Options to Outside Directors under this Plan shall be
automatic and nondiscretionary and shall be made strictly in accordance with the following
provisions:




               (i) No person shall have any discretion to select which Outside Directors shall be granted
Options or to determine the number of Shares to be covered by Options granted to Outside Directors.




               (ii) Each new Outside Director shall be automatically granted an Option to purchase $150,000
in face value of Company stock underlying options based on the closing stock price as reported by
NASDAQ on the day before the grant date (the “First Option”) on the date on which the later of the
following events occurs: (A) the effective date of this Plan, as determined in accordance with
Section 6 hereof, or (B) the date on which such person first becomes an Outside Director, whether
through election by the stockholders of the Company or appointment by the Board to fill a vacancy;
provided, however, that an Inside Director who ceases to be an Inside Director but who remains a
Director shall not receive a First Option.




               (iii) Each Outside Director shall be automatically granted an Option to purchase $40,000 in
face value of Company stock underlying options based on the closing stock price as reported by
NASDAQ on the day before the grant date (a “Subsequent Option”) on the date of the annual meeting
of stockholders of each year provided he or she is then an Outside Director and if as of such date,
he or she shall have served on the Board for at least the preceding six (6) months.




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               (iv) Notwithstanding the provisions of subsections (ii) and (iii) hereof, any exercise of an
Option granted before the Company has obtained shareholder approval of the Plan in accordance with
Section 16 hereof shall be conditioned upon obtaining such shareholder approval of the Plan in
accordance with Section 16 hereof.




               (v) The terms of a First Option granted hereunder shall be as follows:




                    (A) the term of the First Option shall be ten (10) years.




                    (B) the First Option shall be exercisable only while the Outside Director remains a Director
of the Company, except as set forth in Sections 8 and 10 hereof.




                    (C) the exercise price per Share shall be 100% of the Fair Market Value per Share on the date
of grant of the First Option. In the event that the date of grant of the First Option is not a
trading day, the exercise price per Share shall be the Fair Market Value on the next trading day
immediately following the date of grant of the First Option.




                    (D) subject to Section 10 hereof, the First Option shall become exercisable as to 1/4th of the
Shares subject to the First Option on the day before the annual meeting of stockholders of each
year or, if no such meeting is held, on each anniversary of the date of grant, provided that the
Optionee continues to serve as a Director on such dates.




               (vi) The terms of a Subsequent Option granted hereunder shall be as follows:




                    (A) the term of the Subsequent Option shall be ten (10) years.




                    (B) the Subsequent Option shall be exercisable only while the Outside Director remains a
Director of the Company, except as set forth in Sections 8 and 10 hereof.




                    (C) the exercise price per Share shall be 100% of the Fair Market Value per Share on the date
of grant of the Subsequent Option. In the event that the date of grant of the Subsequent Option is
not a trading day, the exercise price per Share shall be the Fair Market Value on the next trading
day immediately following the date of grant of the Subsequent Option.




                    (D) subject to Section 10 hereof, the Subsequent Option shall become exercisable as to 1/3 of
the Shares subject to the Subsequent Option on the day before the annual meeting of stockholders of
each year or, if no such meeting is held, on each anniversary of the date of grant, provided that
the Optionee continues to serve as a Director on such dates.




               (vii) In the event that any Option granted under the Plan would cause the number of Shares
subject to outstanding Options plus the number of Shares previously purchased under Options to
exceed the Pool, then the remaining Shares available for Option grant shall be granted under
Options to the Outside Directors on a pro rata basis. No further grants shall be made until such
time, if any, as additional Shares become available for grant under the Plan through action of the
Board or the stockholders to increase the number of Shares which may be issued under the Plan or
through cancellation or expiration of Options previously granted hereunder.




     5. Eligibility. Options may be granted only to Outside Directors. All Options shall be
automatically granted in accordance with the terms set forth in Section 4 hereof.



     The Plan shall not confer upon any Optionee any right with respect to continuation of service
as a Director or nomination to serve as a Director, nor shall it interfere in any way with any
rights which the Director or the Company may have to terminate the Director’s relationship with the
Company at any time.



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     6. Term of Plan. The Plan shall become effective upon the earlier to occur of its adoption by
the Board or its approval by the stockholders of the Company as described in Section 16 of the
Plan. It shall continue in effect for a term of ten (10) years unless sooner terminated under
Section 11 of the Plan.



     7. Form of Consideration. The consideration to be paid for the Shares to be issued upon
exercise of an Option, including the method of payment, shall consist of (i) cash, (ii) check,
(iii) other shares which (x) in the case of Shares acquired upon exercise of an Option, have been
owned by the Optionee for more than six (6) months on the date of surrender, and (y) have a Fair Market Value on the date of surrender equal to the aggregate
exercise price of the Shares as to which said Option shall be exercised, (iv) consideration
received by the Company under a cashless exercise program implemented by the Company in connection
with the Plan, or (v) any combination of the foregoing methods of payment.



     8. Exercise of Option.



          (a) Procedure for Exercise; Rights as a Shareholder. Any Option granted hereunder shall be
exercisable at such times as are set forth in Section 4 hereof; provided, however, that no Options
shall be exercisable until shareholder approval of the Plan in accordance with Section 16 hereof
has been obtained.




     An Option may not be exercised for a fraction of a Share.



     An Option shall be deemed to be exercised when written notice of such exercise has been given
to the Company in accordance with the terms of the Option by the person entitled to exercise the
Option and full payment for the Shares with respect to which the Option is exercised has been
received by the Company. Full payment may consist of any consideration and method of payment
allowable under Section 7 of the Plan. Until the issuance (as evidenced by the appropriate entry
on the books of the Company or of a duly authorized transfer agent of the Company) of the stock
certificate evidencing such Shares, no right to vote or receive dividends or any other rights as a
shareholder shall exist with respect to the Optioned Stock, notwithstanding the exercise of the
Option. A share certificate for the number of Shares so acquired shall be issued to the Optionee
as soon as practicable after exercise of the Option. No adjustment shall be made for a dividend or
other right for which the record date is prior to the date the stock certificate is issued, except
as provided in Section 10 of the Plan.



     Exercise of an Option in any manner shall result in a decrease in the number of Shares which
thereafter may be available, both for purposes of the Plan and for sale under the Option, by the
number of Shares as to which the Option is exercised.



          (b) Termination of Continuous Status as a Director. Subject to Section 10 hereof, in the
event an Optionee’s status as a Director terminates (other than upon the Optionee’s death or total
and permanent disability (as defined in Section 22(e)(3) of the Code)), the Optionee may exercise
his or her Option, but only within three (3) months following the date of such termination, and
only to the extent that the Optionee was entitled to exercise it on the date of such termination
(but in no event later than the expiration of its ten (10) year term). To the extent that the
Optionee was not entitled to exercise an Option on the date of such termination, and to the extent
that the Optionee does not exercise such Option (to the extent otherwise so entitled) within the
time specified herein, the Option shall terminate.




          (c) Disability of Optionee. In the event Optionee’s status as a Director terminates as a
result of total and permanent disability (as defined in Section 22(e)(3) of the Code), the Optionee
may exercise his or her Option, but only within twelve (12) months following the date of such
termination, and only to the extent that the Optionee was entitled to exercise it on the date of
such termination (but in no event later than the expiration of its ten (10) year term). To the
extent that the Optionee was not entitled to exercise an Option on the date of termination, or if
he or she does not exercise such Option (to the extent otherwise so entitled) within the time
specified herein, the Option shall terminate.




          (d) Death of Optionee. In the event of an Optionee’s death, the Optionee’s estate or a person
who acquired the right to exercise the Option by bequest or inheritance may exercise the Option,
but only within twelve (12) months following the date of death, and only to the extent that the
Optionee was entitled to exercise it on the date of death (but in no event later than the
expiration of its ten (10) year term). To the extent that the Optionee was not entitled to
exercise an Option on the date of death, and to the extent that the Optionee’s estate or a person
who acquired the right to exercise such




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Option does not exercise such Option (to the extent
otherwise so entitled) within the time specified herein, the Option shall terminate.




     9. Non-Transferability of Options. Unless otherwise determined by the Board, the Option may
not be sold, pledged, assigned, hypothecated, transferred, or disposed of in any manner other than
by will or by the laws of descent or distribution and may be exercised, during the lifetime of the
Optionee, only by the Optionee.



     10. Adjustments Upon Changes in Capitalization, Dissolution, Merger or Asset Sale.



          (a) Changes in Capitalization. Subject to any required action by the stockholders of the
Company, the number of Shares covered by each outstanding Option, the number of Shares which have
been authorized for issuance under the Plan but as to which no Options have yet been granted or
which have been returned to the Plan upon cancellation or expiration of an Option, as well as the
price per Share covered by each such outstanding Option, and the number of Shares issuable pursuant
to the automatic grant provisions of Section 4 hereof shall be proportionately adjusted for any
increase or decrease in the number of issued Shares resulting from a stock split, reverse stock
split, stock dividend, combination or reclassification of the Common Stock, or any other increase
or decrease in the number of issued Shares effected without receipt of consideration by the
Company; provided, however, that conversion of any convertible securities of the Company shall not
be deemed to have been “effected without receipt of consideration.” Except as expressly provided
herein, no issuance by the Company of shares of stock of any class, or securities convertible into
shares of stock of any class, shall affect, and no adjustment by reason thereof shall be made with
respect to, the number or price of Shares subject to an Option.




          (b) Dissolution or Liquidation. In the event of the proposed dissolution or liquidation of
the Company, to the extent that an Option has not been previously exercised, it shall terminate
immediately prior to the consummation of such proposed action.




          (c) Merger or Asset Sale. In the event of a merger of the Company with or into another
corporation or the sale of substantially all of the assets of the Company, outstanding Options may
be assumed or equivalent options may be substituted by the successor corporation or a Parent or
Subsidiary thereof (the “Successor Corporation”). If an Option is assumed or substituted for, the
Option or equivalent option shall continue to be exercisable as provided in Section 4 hereof for so
long as the Optionee serves as a Director or a director of the Successor Corporation. Following
such assumption or substitution, if the Optionee’s status as a Director or director of the
Successor Corporation, as applicable, is terminated other than upon a voluntary resignation by the
Optionee, the Option or option shall become fully exercisable, including as to Shares for which it
would not otherwise be exercisable. Thereafter, the Option or option shall remain exercisable in
accordance with Sections 8(b) through (d) above.




     If the Successor Corporation does not assume an outstanding Option or substitute for it an
equivalent option, the Option shall become fully vested and exercisable, including as to Shares for
which it would not otherwise be exercisable. In such event the Board shall notify the Optionee
that the Option shall be fully exercisable for a period of ninety (90) days from the date of such
notice, and upon the expiration of such period the Option shall terminate.



     For the purposes of this Section 10(c), an Option shall be considered assumed if, following
the merger or sale of assets, the Option confers the right to purchase or receive, for each Share
of Optioned Stock subject to the Option immediately prior to the merger or sale of assets, the
consideration (whether stock, cash, or other securities or property) received in the merger or sale
of assets by holders of Common Stock for each Share held on the effective date of the transaction
(and if holders were offered a choice of consideration, the type of consideration chosen by the
holders of a majority of the outstanding Shares). If such consideration received in the merger or
sale of assets is not solely common stock of the successor corporation or its Parent, the
Administrator may, with the consent of the successor corporation, provide for the consideration to
be received upon the exercise of the Option, for each Share of Optioned Stock subject to the
Option, to be solely common stock of the successor corporation or its Parent equal in fair market
value to the per share consideration received by holders of Common Stock in the merger or sale of
assets.



     11. Amendment and Termination of the Plan.



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          (a) Amendment and Termination. The Board may at any time amend, alter, suspend, or
discontinue the Plan, but no amendment, alteration, suspension, or discontinuation shall be made
which would impair the rights of any Optionee under any grant theretofore made, without his or her
consent. In addition, to the extent necessary and desirable to comply with any applicable law,
regulation or stock exchange rule, the Company shall obtain shareholder approval of any Plan
amendment in such a manner and to such a degree as required.




          (b) Effect of Amendment or Termination. Any such amendment or termination of the Plan shall
not affect Options already granted and such Options shall remain in full force and effect as if
this Plan had not been amended or terminated.




     12. Time of Granting Options. The date of grant of an Option shall, for all purposes, be the
date determined in accordance with Section 4 hereof.



     13. Conditions Upon Issuance of Shares. Shares shall not be issued pursuant to the exercise
of an Option unless the exercise of such Option and the issuance and delivery of such Shares
pursuant thereto shall comply with all relevant provisions of law, including, without limitation,
the Securities Act of 1933, as amended, the Exchange Act, the rules and regulations promulgated
thereunder, state securities laws, and the requirements of any stock exchange upon which the Shares
may then be listed, and shall be further subject to the approval of counsel for the Company with
respect to such compliance.



     As a condition to the exercise of an Option, the Company may require the person exercising
such Option to represent and warrant at the time of any such exercise that the Shares are being
purchased only for investment and without any present intention to sell or distribute such Shares,
if, in the opinion of counsel for the Company, such a representation is required by any of the
aforementioned relevant provisions of law.



     Inability of the Company to obtain authority from any regulatory body having jurisdiction,
which authority is deemed by the Company’s counsel to be necessary to the lawful issuance and sale
of any Shares hereunder, shall relieve the Company of any liability in respect of the failure to
issue or sell such Shares as to which such requisite authority shall not have been obtained.



     14. Reservation of Shares. The Company, during the term of this Plan, will at all times
reserve and keep available such number of Shares as shall be sufficient to satisfy the requirements
of the Plan.



     15. Option Agreement. Options shall be evidenced by written option agreements in such form as
the Board shall approve.



     16. Shareholder Approval. Continuance of the Plan shall be subject to approval by the
stockholders of the Company at or prior to the first annual meeting of stockholders held subsequent
to the granting of an Option hereunder. Such shareholder approval shall be obtained in the degree
and manner required under applicable state and federal law and any stock exchange rules.



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TASER INTERNATIONAL, INC.




2004 DIRECTOR STOCK OPTION PLAN




DIRECTOR OPTION AGREEMENT




     TASER International, Inc., a Delaware corporation (the “Company”), has granted to ___
(the “Optionee”), an option to purchase a total of [___(___)] shares of the Company’s
Common Stock (the “Optioned Stock”), at the price determined as provided herein, and in all
respects subject to the terms, definitions and provisions of the Company’s 2004 Director Stock
Option Plan (the “Plan”) adopted by the Company which is incorporated herein by reference. The
terms defined in the Plan shall have the same defined meanings herein.



     1. Nature of the Option. This Option is a nonstatutory option and is not intended to qualify
for any special tax benefits to the Optionee.



     2. Exercise Price. The exercise price is $___for each share of Common Stock.



     3. Exercise of Option. This Option shall be exercisable during its term in accordance with
the provisions of Section 8 of the Plan as follows:



          (a) Right to Exercise.




               (i) This Option shall become exercisable in installments cumulatively with respect to 1/4th of
the Shares subject to the Option on the day before the annual meeting of stockholders of each year
or, if no such meeting is held, on each anniversary of the date of grant, provided that the
Optionee continues to serve as a Director on such dates; provided, however, that in no event shall
any Option be exercisable prior to the date the stockholders of the Company approve the Plan.




               (ii) This Option may not be exercised for a fraction of a share.




               (iii) In the event of Optionee’s death, disability or other termination of service as a
Director, the exercisability of the Option is governed by Section 8 of the Plan.




          (b) Method of Exercise. This Option shall be exercisable by written notice which shall state
the election to exercise the Option and the number of Shares in respect of which the Option is
being exercised. Such written notice, in the form attached hereto as Exhibit A, shall be signed by
the Optionee and shall be delivered in person or by certified mail to the Secretary of the Company.
The written notice shall be accompanied by payment of the exercise price.




     4. Method of Payment. Payment of the exercise price shall be by any of the following, or a
combination thereof, at the election of the Optionee:



          (a) cash;




          (b) check;




          (c) surrender of other shares which (x) in the case of Shares acquired upon exercise of an
Option, have been owned by the Optionee for more than six (6) months on the date of surrender, and
(y) have a Fair Market Value on the date of surrender equal to the aggregate exercise price of the
Shares as to which said Option shall be exercised; or




          (d) delivery of a properly executed exercise notice together with such other documentation as
the Company and the broker, if applicable, shall require to effect an exercise of the Option and
delivery to the Company of the sale or loan proceeds required to pay the exercise price.




 









 





     5. Restrictions on Exercise. This Option may not be exercised if the issuance of such Shares
upon such exercise or the method of payment of consideration for such shares would constitute a
violation of any applicable federal or state securities or other law or regulations, or if such
issuance would not comply with the requirements of any stock exchange upon which the Shares may
then be listed. As a condition to the exercise of this Option, the Company may require Optionee to
make any representation and warranty to the Company as may be required by any applicable law or
regulation.



     6. Non-Transferability of Option. This Option may not be transferred in any manner otherwise
than by will or by the laws of descent or distribution and may be exercised during the lifetime of
Optionee only by the Optionee. The terms of this Option shall be binding upon the executors,
administrators, heirs, successors and assigns of the Optionee.



     7. Term of Option. This Option may not be exercised more than ten (10) years from the date of
grant of this Option, and may be exercised during such period only in accordance with the Plan and
the terms of this Option.



     8. Taxation Upon Exercise of Option. Optionee understands that, upon exercise of this Option,
he or she will recognize income for tax purposes in an amount equal to the excess of the then Fair
Market Value of the Shares purchased over the exercise price paid for such Shares. Since the
Optionee is subject to Section 16(b) of the Securities Exchange Act of 1934, as amended, under
certain limited circumstances the measurement and timing of such income (and the commencement of
any capital gain holding period) may be deferred, and the Optionee is advised to contact a tax
advisor concerning the application of Section 83 in general and the availability of a Section 83(b)
election in particular in connection with the exercise of the Option. Upon a resale of such Shares
by the Optionee, any difference between the sale price and the Fair Market Value of the Shares on
the date of exercise of the Option, to the extent not included in income as described above, will
be treated as capital gain or loss.



	 	 	 	 	 
	Date of Grant: 	TASER INTERNATIONAL, INC.,

a Delaware corporation

 	 
	 	By:  	 	 
	 	 	 	 
	 	 	 	 
	 




     Optionee acknowledges receipt of a copy of the Plan, a copy of which is attached hereto, and
represents that he or she is familiar with the terms and provisions thereof, and hereby accepts
this Option subject to all of the terms and provisions thereof. Optionee hereby agrees to accept
as binding, conclusive and final all decisions or interpretations of the Board upon any questions
arising under the Plan.



	 	 	 	 	 	 	 
	Dated:

	 	 
	 	Optionee
	 	 
	 

	 	 
	 	 	 	 





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EXHIBIT A




DIRECTOR OPTION EXERCISE NOTICE




TASER International, Inc.




Attention: Corporate Secretary




     1. Exercise of Option. The undersigned (“Optionee”) hereby elects to exercise Optionee’s
option to purchase shares of the Common Stock (the “Shares”) of TASER International, Inc.
(the “Company”) under and pursuant to the Company’s 2004 Director Stock Option Plan and the
Director Option Agreement dated                      (the “Agreement”).



     2. Representations of Optionee. Optionee acknowledges that Optionee has received, read and
understood the Agreement.



     3. Federal Restrictions on Transfer. Optionee understands that the Shares must be held
indefinitely unless they are registered under the Securities Act of 1933, as amended (the “1933
Act”), or unless an exemption from such registration is available, and that the certificate(s)
representing the Shares may bear a legend to that effect. Optionee understands that the Company is
under no obligation to register the Shares and that an exemption may not be available or may not
permit Optionee to transfer Shares in the amounts or at the times proposed by Optionee.



     4. Tax Consequences. Optionee understands that Optionee may suffer adverse tax consequences
as a result of Optionee’s purchase or disposition of the Shares. Optionee represents that Optionee
has consulted with any tax consultant(s) Optionee deems advisable in connection with the purchase
or disposition of the Shares and that Optionee is not relying on the Company for any tax advice.



     5. Delivery of Payment. Optionee herewith delivers to the Company the aggregate purchase
price for the Shares that Optionee has elected to purchase and has made provision for the payment
of any federal or state withholding taxes required to be paid or withheld by the Company.



     6. Entire Agreement. The Agreement is incorporated herein by reference. This Exercise Notice
and the Agreement constitute the entire agreement of the parties and supersede in their entirety
all prior undertakings and agreements of the Company and Optionee with respect to the subject
matter hereof. This Exercise Notice and the Agreement are governed by Delaware law except for that
body of law pertaining to conflict of laws.



	 	 	 	 	 	 	 
	Submitted by:	 	 	 	Accepted by:  
	 
	 	 	 	 	 	 
	OPTIONEE:	 	 	 	TASER INTERNATIONAL, INC.
	 
	 	 	 	 	 	 
	 

	 	 	 	By:	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	 

	 	 	 	Its:	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	 

	 	 	 	Address:	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Dated:

	 	 	 	Dated:	 	 
	 

	 	 
	 	 	 	 






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