Exhibit 10.35


 


SUBSCRIPTION AGREEMENT


 


THIS SUBSCRIPTION
AGREEMENT (this “Agreement”), is dated as of __________ __, 2020, by and between GROM SOCIAL ENTERPRISES,
INC., a Florida corporation (the “Company”), and the subscriber identified on the signature page hereto (each
a “Subscriber” and collectively “Subscribers”).


 


WHEREAS, the
Company and the Subscribers are executing and delivering this Agreement in reliance upon an exemption from securities registration
afforded by the provisions of Section 4(2), Section 4(6) and/or Regulation D (“Regulation D”) as promulgated
by the United States Securities and Exchange Commission (the “Commission”) under the Securities Act of 1933,
as amended (the “1933 Act”); and


 


WHEREAS, the
parties desire that, upon the terms and subject to the conditions contained herein, the Company shall issue and sell to the Subscribers,
as provided herein, and the Subscribers, in the aggregate, shall purchase up to a maximum of 10,000,000 shares, on a rolling basis,
of Series B 8% Convertible Preferred Stock of the Company (the “Preferred Stock”), the terms, preferences and
rights as described in the Certificate of Designation of the Series B Convertible Preferred Stock which is annexed hereto as Exhibit
A, convertible into shares of the Company's Common Stock, $0.001 par value (the "Common Stock"), as described
therein. The per share purchase price of each share of Preferred Stock shall be $1.00 per share (the “Purchase Price”).
The Preferred Stock and the shares of Common Stock issuable upon conversion of the Preferred Stock (the “Conversion Shares”)
are collectively referred to herein as the "Securities".


 


NOW, THEREFORE,
in consideration of the mutual covenants and other agreements contained in this Agreement, the Company and the Subscribers hereby
agree as follows:


 


1.       Purchase;
Closing Date. The Subscriber understands and acknowledges that the Purchase Price to be remitted to the Company in exchange
for the Preferred Stock is as indicated on the signature page hereto. The Subscriber’s delivery of this Agreement to the
Company shall be accompanied by payment of the Purchase Price, payable in United States Dollars, by wire transfer, or check of
immediately available funds delivered contemporaneously with the Subscriber’s delivery of this Agreement to the Company in
accordance with the wire instructions provided on Exhibit C. The Subscriber understands and agrees that, subject
to Section 2 and applicable laws, by executing this Agreement, it is entering into a binding agreement.


 


The “Closing
Date” shall be the date that the Purchase Price is transmitted by wire transfer or otherwise credited to or for the benefit
of the Company and the Company accepts the Purchase Price, as indicated by sending the Subscriber a signature page to this Agreement,
duly executed by the Company. Subject to the satisfaction or waiver of the terms and conditions of this Agreement, on the Closing
Date, each Subscriber shall purchase and the Company shall sell to each Subscriber the number of shares of Preferred Stock in the
amount designated on the signature page hereto for the Purchase Price indicated thereon.


 


The Subscriber agrees
and acknowledges that there is no minimum amount to be raised in this offering, and therefore the Company will accept the Purchase
Price upon the transmittal thereof. Accordingly, the Company may not raise sufficient funds to effectuate its business plan.


 


The Subscriber further
agrees and acknowledges that the majority of the shares of the Preferred Stock to be issued shall be issued to current securityholders
of the Company who are converting their outstanding debt and equity securities to shares of the Preferred Stock.


 


 


 






    	 	1	 



     


    

 


2.       Subscriber's
Representations and Warranties. Each Subscriber hereby represents and warrants to and agrees with the Company only as to such
Subscriber that:


 


(a)       Organization
and Standing of the Subscribers. If the Subscriber is an entity, such Subscriber is a corporation, partnership or other
entity duly incorporated or organized, validly existing and in good standing under the laws of the jurisdiction of its incorporation
or organization.


 


(b)       Authorization
and Power. Each Subscriber has the requisite power and authority to enter into and perform this Agreement and to purchase
the Preferred Stock being sold to it hereunder. The execution, delivery and performance of this Agreement by such Subscriber and
the consummation by it of the transactions contemplated hereby and thereby have been duly authorized by all necessary corporate
or partnership action, and no further consent or authorization of such Subscriber or its Board of Directors, stockholders, partners,
members, trustees, as the case may be, is required. This Agreement has been duly authorized, executed and delivered by Subscriber
and constitutes, or shall constitute when executed and delivered, a valid and binding obligation of the Subscriber enforceable
against the Subscriber in accordance with the terms thereof.


 


(c)       No
Conflicts. The execution, delivery and performance of this Agreement and the consummation by such Subscriber of the transactions
contemplated hereby or relating hereto do not and will not (i) result in a violation of such Subscriber’s charter documents
or bylaws or other organizational documents or (ii) conflict with, or constitute a default (or an event which with notice or lapse
of time or both would become a default) under, or give to others any rights of termination, amendment, acceleration or cancellation
of any agreement, indenture or instrument or obligation to which such Subscriber is a party or by which its properties or assets
are bound, or result in a violation of any law, rule, or regulation, or any order, judgment or decree of any court or governmental
agency applicable to such Subscriber or its properties (except for such conflicts, defaults and violations as would not, individually
or in the aggregate, have a material adverse effect on such Subscriber). Such Subscriber is not required to obtain any consent,
authorization or order of, or make any filing or registration with, any court or governmental agency in order for it to execute,
deliver or perform any of its obligations under this Agreement or to purchase the Securities in accordance with the terms hereof,
provided that for purposes of the representation made in this sentence, such Subscriber is assuming and relying upon the accuracy
of the relevant representations and agreements of the Company herein.


 


(d)       Information
on Company. The Subscriber has been furnished with all information it has requested from the Company and considered all factors
the Subscriber deems material in deciding on the advisability of investing in the Securities. The Subscriber further understands
that the Company has been filing reports with the Commission. The Subscriber has been afforded the opportunity to ask questions
of and receive answers from duly authorized officers and/or other representatives of the Company and any additional information
which the Subscriber had requested. The Subscriber has also reviewed all information including the terms hereof and of the Preferred
Stock, with their counsel and professional tax or economic advisers and understands the risks relating hereto.


 


The Subscriber understands
that the auditors of the Company have expressed their concern as to the viability of the Company and issued a going concern opinion
with respect to the Company.


 


(e)       Information
on Subscriber. The Subscriber is, and will be at the time of the conversion of the Preferred Stock, an "accredited
investor", as such term is defined in Regulation D promulgated by the Commission under the 1933 Act, is experienced in
investments and business matters, has made investments of a speculative nature and has purchased securities of companies in private
placements in the past and, with its representatives, has such knowledge and experience in financial, tax and other business matters
as to enable the Subscriber to utilize the information made available by the Company to evaluate the merits and risks of and to
make an informed investment decision with respect to the proposed purchase, which represents a speculative investment. The Subscriber
has the authority and is duly and legally qualified to purchase and own the Securities. The Subscriber is able to bear the risk
of such investment for an indefinite period and to afford a complete loss thereof. The information set forth on the signature page
hereto and on the accredited investor questionnaire annexed hereto as Exhibit B regarding the Subscriber is accurate.


 


 


 






    	 	2	 



     


    

 


(f)       Purchase
of Preferred Stock. On the Closing Date, the Subscriber will purchase the Preferred Stock as principal for its own account
for investment only and not with a view toward, or for resale in connection with, the public sale or any distribution thereof.
The Subscriber has been advised of and acknowledges that (i) there is currently no market for the Preferred Stock being purchased
herein, and (ii) it is not intended that any market will develop for the Preferred Stock.


 


(g)      Compliance
with Securities Act. The Subscriber understands and agrees that the Securities have not been registered under the 1933 Act
or any applicable state securities laws, by reason of their issuance in a transaction that does not require registration under
the 1933 Act (based in part on the accuracy of the representations and warranties of Subscriber contained herein), and that such
Securities must be held indefinitely unless a subsequent disposition is registered under the 1933 Act or any applicable state securities
laws or is exempt from such registration.


 


(h)      Experience
of Subscriber. The Subscriber is (i) experienced in making investments of the kind described in this Agreement and the related
documents, (ii) able, by reason of the business and financial experience of its officers (if an entity) and professional advisors
(who are not affiliated with or compensated in any way by the Company or any of its affiliates or selling agents), to protect its
own interests in connection with the transactions described in this Agreement, and the related documents, and (iii) able to afford
the entire loss of its investment in the Securities. The Subscriber’s overall commitment to investments which are not readily
marketable is not disproportionate to the Subscriber's net worth, and an investment in the Securities will not cause such overall
commitment to become excessive.


 


(i)       No other representations.
The Subscriber is not relying on the Company, or its affiliates or agents with respect to economic considerations involved in this
investment. The Subscriber has relied solely on its own advisors. No representations or warranties have been made to the Subscriber
by the Company, or any officer, employee, agent, affiliate or subsidiary of the Company, other than the representations of the
Company contained herein, and in subscribing for the Securities the Subscriber is not relying upon any representations other than
those contained herein.


 


(j)       Shares Legend.
The Preferred Stock and the Conversion Shares shall bear the following or similar legend:


 


"THE SHARES REPRESENTED BY THIS
CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED. THESE SHARES MAY NOT BE SOLD, OFFERED FOR SALE,
PLEDGED OR HYPOTHECATED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT UNDER SUCH SECURITIES ACT OR ANY APPLICABLE STATE
SECURITIES LAW OR AN OPINION OF COUNSEL REASONABLY SATISFACTORY TO [THE COMPANY] THAT SUCH REGISTRATION IS NOT REQUIRED."


 


(k)      Communication
of Offer. The offer to sell the Securities was directly communicated to the Subscriber by the Company. At no time was the Subscriber
presented with or solicited by any leaflet, newspaper or magazine article, radio or television advertisement, or any other form
of general advertising or solicited or invited to attend a promotional meeting otherwise than in connection and concurrently with
such communicated offer.


 


(l)       Authority;
Enforceability. This Agreement and other agreements delivered together with this Agreement or in connection herewith have been
duly authorized, executed and delivered by the Subscriber and are valid and binding agreements enforceable in accordance with their
terms, subject to bankruptcy, insolvency, fraudulent transfer, reorganization, moratorium and similar laws of general applicability
relating to or affecting creditors’ rights generally and to general principles of equity; and Subscriber has full power and
authority necessary to enter into this Agreement and such other agreements and to perform its obligations hereunder and under all
other agreements entered into by the Subscriber relating hereto.


 


(m)     Restricted
Securities. Subscriber understands that the Securities have not been registered under the 1933 Act and such Subscriber will
not sell, offer to sell, assign, pledge, hypothecate or otherwise transfer any of the Securities unless pursuant to an effective
registration statement under the 1933 Act, or unless an exemption from registration is available. Notwithstanding anything to the
contrary contained in this Agreement, such Subscriber may transfer (with an opinion of counsel satisfactory to the Company and
its counsel) the Securities to its Affiliates (as defined below), provided that each such Affiliate is an “accredited investor”
under Regulation D and such Affiliate agrees to be bound by the terms and conditions of this Agreement. For the purposes of this
Agreement, an “Affiliate” of any person or entity means any other person or entity directly or indirectly controlling,
controlled by or under direct or indirect common control with such person or entity. Affiliate includes each subsidiary of the
Company. For purposes of this definition, “control” means the power to direct the management and policies of
such person or firm, directly or indirectly, whether through the ownership of voting securities, by contract or otherwise.


 


 


 






    	 	3	 



     


    

 


(n)      No
Governmental Review. Each Subscriber understands that no United States federal or state agency or any other governmental or
state agency has passed on or made recommendations or endorsement of the Securities or the suitability of the investment in the
Securities nor have such authorities passed upon or endorsed the merits of the offering of the Securities.


 


(o)      Correctness
of Representations. Each Subscriber represents that the foregoing representations and warranties are true and accurate as of
the date hereof and shall survive the issuance and delivery of the Conversion Shares. If, in any respect, those representations
and warranties shall not be true and accurate prior to delivery of the payment pursuant to Section 1 above, the undersigned shall
immediately give written notice to the Company specifying which representations and warranties are not true and accurate and the
reason therefor. It is specifically understood and agreed by the Subscriber that neither the Company nor its officers or directors
has made, nor by this Agreement shall be construed to make, directly or indirectly, explicitly or by implication, any representation,
warranty, projection, assumption, promise, covenant, opinion, recommendation or other statement of any kind or nature with respect
to the anticipated operations, investment returns, cash flows, profits or losses of the Company.


 


(p)      Survival.
The foregoing representations and warranties shall survive the Closing Date for a period of three years.


 


3.       Company
Representations and Warranties. The Company represents and warrants to and agrees with each Subscriber that:


 


(a)       Due
Incorporation. The Company is a corporation or other entity duly incorporated or organized, validly existing and in good standing
under the laws of the State of Florida and has the requisite corporate power to own its properties and to carry on its business
as presently conducted.


 


(b)       Authority;
Enforceability. This Agreement and any other agreements delivered together with this Agreement or in connection herewith (collectively
“Transaction Documents”) have been duly authorized, executed and delivered by the Company and are valid and
binding agreements of the Company enforceable in accordance with their terms, subject to bankruptcy, insolvency, fraudulent transfer,
reorganization, moratorium and similar laws of general applicability relating to or affecting creditors' rights generally and to
general principles of equity. The Company has full corporate power and authority necessary to enter into and deliver the Transaction
Documents and to perform its obligations thereunder.


 


(c)       Consents.
No consent, approval, authorization or order of any court, governmental agency or body or arbitrator having jurisdiction over the
Company, or any of its Affiliates nor the Company's shareholders is required for the execution by the Company of the Transaction
Documents and compliance and performance by the Company of its obligations under the Transaction Documents, including, without
limitation, the issuance and sale of the Securities. The Transaction Documents and the Company’s performance of its obligations
thereunder has been unanimously approved by the Company’s Board of Directors.


 


(d)       No
Violation or Conflict. Assuming the representations and warranties of the Subscribers in Section 2 are true and correct, neither
the issuance and sale of the Securities nor the performance of the Company’s obligations under this Agreement and all other
agreements entered into by the Company relating thereto by the Company will violate, conflict with, result in a breach of, or constitute
a default (or an event which with the giving of notice or the lapse of time or both would be reasonably likely to constitute a
default) under (A) the articles or certificate of incorporation, charter or bylaws of the Company, (B) to the Company's knowledge,
any decree, judgment, order, law, treaty, rule, regulation or determination applicable to the Company of any court, governmental
agency or body, or arbitrator having jurisdiction over the Company or over the properties or assets of the Company or any of its
Affiliates, (C) the terms of any bond, debenture, note or any other evidence of indebtedness, or any agreement, stock option or
other similar plan, indenture, lease, mortgage, deed of trust or other instrument to which the Company or any of its Affiliates
is a party, by which the Company or any of its Affiliates is bound, or to which any of the properties of the Company or any of
its Affiliates is subject.


 


 


 






    	 	4	 



     


    

 


(e)       The
Securities. The Securities upon issuance:


 


(i)         are,
or will be, free and clear of any security interests, liens, claims or other encumbrances, subject to restrictions upon transfer
under the 1933 Act and any applicable state securities laws;


 


(ii)        have
been, or will be, duly and validly authorized and issued, fully paid and non-assessable;


 


(iii)       will
not have been issued or sold in violation of any preemptive or other similar rights of the holders of any securities of the Company;


 


(iv)       will
not subject the holders thereof to personal liability by reason of being such holders; and


 


(v)        assuming
the representations warranties of the Subscribers as set forth in Section 2 hereof are true and correct, will not result in a violation
of Section 5 under the 1933 Act.


 


(f)       No
Integrated Offering. Neither the Company, nor any of its Affiliates, nor any person acting on its or their behalf, has directly
or indirectly made any offers or sales of any security or solicited any offers to buy any security under circumstances that would
cause the offer of the Securities pursuant to this Agreement to be integrated with prior offerings by the Company for purposes
of the 1933 Act or any applicable stockholder approval provisions. Nor will the Company nor any of its Affiliates take any action
or steps that would cause the offer or issuance of the Securities to be integrated with other offerings which would impair the
exemptions relied upon in this offering or the Company’s ability to timely comply with its obligations hereunder. The Company
will not conduct any offering other than the transactions contemplated hereby that will be integrated with the offer or issuance
of the Securities, which would impair the exemptions relied upon in this offering or the Company’s ability to timely comply
with its obligations hereunder.


 


(g)       No
General Solicitation. Neither the Company, nor any of its Affiliates, nor to its knowledge, any person acting on its or their
behalf, has engaged in any form of general solicitation or general advertising (within the meaning of Regulation D under the 1933
Act) in connection with the offer or sale of the Securities.


 


(h)       Correctness
of Representations. The Company represents that the foregoing representations and warranties are true and correct as of the
date hereof in all material respects, and, unless the Company otherwise notifies the Subscribers prior to the Closing Date, shall
be true and correct in all material respects as of the Closing Date.


 


4.       Indemnification.


 


(a)      The
Company agrees to indemnify, hold harmless, reimburse and defend the Subscribers, the Subscribers' officers, directors, agents,
Affiliates, control persons, and principal shareholders, against any claim, cost, expense, liability, obligation, loss or damage
(including reasonable legal fees) of any nature, incurred by or imposed upon the Subscriber or any such person which results, arises
out of or is based upon (i) any material misrepresentation by Company or breach of any warranty by Company in this Agreement or
in any Exhibits attached hereto, or other agreement delivered pursuant hereto; or (ii) after any applicable notice and/or cure
periods, any breach or default in performance by the Company of any covenant or undertaking to be performed by the Company hereunder,
or any other agreement entered into by the Company and Subscriber relating hereto.


 


(b)      Each
Subscriber agrees to indemnify, hold harmless, reimburse and defend the Company and each of the Company’s officers, directors,
agents, Affiliates, control persons against any claim, cost, expense, liability, obligation, loss or damage (including reasonable
legal fees) of any nature, incurred by or imposed upon the Company or any such person which results, arises out of or is based
upon (i) any misrepresentation by such Subscriber in this Agreement or in any Exhibits attached hereto, or other agreement delivered
pursuant hereto; or (ii) after any applicable notice and/or cure periods, any breach or default in performance by such Subscriber
of any covenant or undertaking to be performed by such Subscriber hereunder, or any other agreement entered into by the Company
and Subscribers, relating hereto.


 


 


 






    	 	5	 



     


    

 


5.        Miscellaneous.


 


(a)      Notices.
All notices, demands, requests, consents, approvals, and other communications required or permitted hereunder shall be in writing
and, unless otherwise specified herein, shall be (i) personally served, (ii) deposited in the mail, registered or certified, return
receipt requested, postage prepaid, (iii) delivered by reputable air courier service with charges prepaid, or (iv) transmitted
by hand delivery, telegram, or facsimile, addressed as set forth below or to such other address as such party shall have specified
most recently by written notice. Any notice or other communication required or permitted to be given hereunder shall be deemed
effective (a) upon hand delivery or delivery by facsimile, with accurate confirmation generated by the transmitting facsimile machine,
at the address or number designated below (if delivered on a business day during normal business hours where such notice is to
be received), or the first business day following such delivery (if delivered other than on a business day during normal business
hours where such notice is to be received) or (b) on the second business day following the date of mailing by express courier service,
fully prepaid, addressed to such address, or upon actual receipt of such mailing, whichever shall first occur. The addresses for
such communications shall be: (i) if to the Company, to: Grom Social Enterprises, Inc., 2060 NW Boca Raton Blvd. #6 Boca Raton,
Florida 33431, (ii) if to the Subscriber, to: the one or more addresses and telecopier numbers indicated on the signature pages
hereto.


 


(b)      Entire
Agreement; Assignment. This Agreement and other documents delivered in connection herewith represent the entire agreement between
the parties hereto with respect to the subject matter hereof and may be amended only by a writing executed by both parties. Neither
the Company nor the Subscribers have relied on any representations not contained or referred to in this Agreement and the documents
delivered herewith. No right or obligation of the Subscriber shall be assigned without prior notice to and the written consent
of the Company.


 


(c)      Counterparts/Execution.
This Agreement may be executed in any number of counterparts and by the different signatories hereto on separate counterparts,
each of which, when so executed, shall be deemed an original, but all such counterparts shall constitute but one and the same instrument.
The delivery of an executed counterpart of this Agreement by electronic means, including by facsimile or by "pdf" attachment
to email, shall be deemed to be valid delivery thereof binding upon all the parties hereto.


 


(d)      Law
Governing this Agreement. This Agreement shall be governed by and construed in accordance with the laws of the State of Florida
without regard to principles of conflicts of laws. Any action brought by either party against the other concerning the transactions
contemplated by this Agreement shall be brought only in the state courts of Florida or in the federal courts located in the state
and county of Florida located in Palm Beach County, Florida. The parties to this Agreement hereby irrevocably waive any objection
to jurisdiction and venue of any action instituted hereunder and shall not assert any defense based on lack of jurisdiction or
venue or based upon forum non conveniens. The prevailing party shall be entitled to recover from the other party its reasonable
attorneys’ fees and costs. The parties executing this Agreement and other agreements referred to herein or delivered in connection
herewith on behalf of the Subscriber agree to submit to the in personam jurisdiction of such courts. In the event that any provision
of this Agreement or any other agreement delivered in connection herewith is invalid or unenforceable under any applicable statute
or rule of law, then such provision shall be deemed inoperative to the extent that it may conflict therewith and shall be deemed
modified to conform with such statute or rule of law. Any such provision which may prove invalid or unenforceable under any law
shall not affect the validity or enforceability of any other provision of any agreement. IN ANY ACTION, SUIT, OR PROCEEDING
IN ANY JURISDICTION BROUGHT BY ANY PARTY AGAINST ANY OTHER PARTY, THE PARTIES EACH KNOWINGLY AND INTENTIONALLY, TO THE GREATEST
EXTENT PERMITTED BY APPLICABLE LAW, HEREBY ABSOLUTELY, UNCONDITIONALLY, IRREVOCABLY AND EXPRESSLY WAIVES FOREVER TRIAL BY JURY.


 


(e)      Independent
Nature of Subscribers.     The Company acknowledges that the obligations of each Subscriber under the Transaction
Documents are several and not joint with the obligations of any other Subscriber, and no Subscriber shall be responsible in any
way for the performance of the obligations of any other Subscriber under the Transaction Documents. The Company acknowledges that
each Subscriber has represented that the decision of each Subscriber to purchase Securities has been made by such Subscriber independently
of any other Subscriber and independently of any information, materials, statements or opinions as to the business, affairs, operations,
assets, properties, liabilities, results of operations, condition (financial or otherwise) or prospects of the Company which may
have been made or given by any other Subscriber or by any agent or employee of any other Subscriber, and no Subscriber or any of
its agents or employees shall have any liability to any Subscriber (or any other person) relating to or arising from any such information,
materials, statements or opinions.  The Company acknowledges that nothing contained in any Transaction Document, and no action
taken by any Subscriber pursuant hereto or thereto shall be deemed to constitute the Subscribers as a partnership, an association,
a joint venture or any other kind of entity, or create a presumption that the Subscribers are in any way acting in concert or as
a group with respect to such obligations or the transactions contemplated by the Transaction Documents.  The Company acknowledges
that each Subscriber shall be entitled to independently protect and enforce its rights, including without limitation, the rights
arising out of the Transaction Documents, and it shall not be necessary for any other Subscriber to be joined as an additional
party in any proceeding for such purpose.  The Company acknowledges that it has elected to provide all Subscribers with the
same terms and Transaction Documents for the convenience of the Company and not because Company was required or requested to do
so by the Subscribers.  The Company acknowledges that such procedure with respect to the Transaction Documents in no way creates
a presumption that the Subscribers are in any way acting in concert or as a group with respect to the Transaction Documents or
the transactions contemplated thereby.


 


Remainder of Page
Intentionally Omitted; Signature Pages to Follow


 


 


 






    	 	6	 



     


    

 




SIGNATURE PAGE TO SUBSCRIPTION AGREEMENT


 


 


 


Please acknowledge
your acceptance of the foregoing Subscription Agreement by signing and returning a copy to the Company; the Agreement shall become
a binding agreement between us upon the execution by the Company.


 


 


	 	GROM SOCIAL ENTERPRISES, INC.
	 	 
	 	 
	 	By:___________________________________
	 	Name:
	 	Title:
	 	 
	 	Dated: _________________, 2020








 


 


	SUBSCRIBER	PURCHASE PRICE AND AMOUNT OF SHARES OF PREFERED STOCK
	
        Name of Subscriber:

         

        __________________________________________________________

         

        Address: __________________________________________________

         

        _________________________________________________________

         

        Fax No.: __________________________________________________

         

        Email address: ________________________________________

         

         

        Taxpayer ID# (if applicable): __________________________________

         

         

         

        _________________________________________________________

        (Signature)

        By:

         
	 


 


 


If an individual, provide copy of government issued identification,
such as passport or drivers' license


 


If an entity, provide copy of articles of incorporation,
certificate of formation or other documentation


 


 


 






    	 	7