EXHIBIT 10.7


 


FORM OF INVESTMENT
MANAGEMENT TRUST AGREEMENT


 


This Agreement is made as of [            ]
[    ], 2007 by and between Information Services Group, Inc.
(the “Company”) and Continental Stock Transfer & Trust Company
(the “Trustee”).


 


WHEREAS, the Company’s Registration Statement on Form S-1,
as amended, No. 333-136536 (together with any registration statement filed
pursuant to Rule 462(b), the “Registration Statement”), for its
initial public offering of securities (the “IPO”) has been declared
effective as of the date hereof by the Securities and Exchange Commission (the “Effective
Date”); and


 


WHEREAS, Deutsche Bank Securities Inc. and Morgan
Joseph & Co. Inc. are acting as the underwriters (the “Underwriters”)
in the IPO; and


 


WHEREAS, the Company has completed a private placement
of 6,000,000 securities for an aggregate purchase price of $6,000,000 (the “Private
Placement”);and


 


WHEREAS, as described in the Registration Statement,
and in accordance with the Company’s Certificate of Incorporation, $148,650,000
(inclusive of the Deferred Discount as defined below) of the proceeds of the
IPO and the sale of securities in a private placement simultaneously with the
IPO ($170,250,000 if the Underwriters’ over-allotment option is exercised in
full) will be delivered to the Trustee to be deposited and held in a trust
account for the benefit of the Company and the holders of the Company’s common
stock, par value $0.001 per share, issued in the IPO (the amount to be
delivered to the Trustee will be referred to herein as the “Property”;
the stockholders for whose benefit the Trustee shall hold the Property will be
referred to as the “Public Stockholders,” and the Public Stockholders
and the Company will be referred to together as the “Beneficiaries”);
and


 


WHEREAS, a portion of the Property consists of
$4,500,000 (or $5,175,000 if the Underwriter’s over-allotment option is
exercised in full) attributable to the Underwriters’ discount (“Deferred
Discount”) which the Underwriters have agreed to deposit in the Trust
Account (defined below); and


 


WHEREAS, the Company and the Trustee desire to enter
into this Agreement to set forth the terms and conditions pursuant to which the
Trustee shall hold the Property.


 


IT IS AGREED:


 


1.                                       Agreements and Covenants of Trustee. The Trustee hereby agrees and covenants to:


 


(a)                                  Hold
the Property in trust for the Beneficiaries in accordance with the terms of
this Agreement, in a segregated trust account (“Trust Account”)
established by the Trustee at a branch of [                          ]
selected by the Trustee;


 

















 


(b)                                 Manage,
supervise and administer the Trust Account subject to the terms and conditions
set forth herein;


 


(c)                                  In
a timely manner, upon the written instruction of the Company, to invest and
reinvest the Property in any “Government Security” within the meaning of Section 2(a)(16)
of the Investment Company Act of 1940, as amended, having a maturity of 180
days or less, or in money market funds selected by the Company meeting the
conditions specified in Rule 2a-7 promulgated under the Investment Company
Act of 1940, as amended, as determined by the Company;


 


(d)                                 Collect
and receive, when due, all principal and income arising from the Property,
which income, net of taxes, shall become part of the “Property,” as such term
is used herein;


 


(e)                                  Notify
the Company of all communications received by it with respect to any Property
which communications require that notice be given by the Company or action be
taken by the Company;


 


(f)                                    Supply
any necessary information or documents as may be requested by the Company
in connection with the Company’s preparation of the tax returns relating to
income from the Property in the Trust Account or otherwise;


 


(g)                                 Participate
in any plan or proceeding for protecting or enforcing any right or interest
arising from the Property if, as and when instructed by the Company in writing
to do so;


 


(h)                                 Render
to the Company and to the Underwriters, and to such other person as the Company
may instruct, monthly written statements of the activities of and amounts
in the Trust Account reflecting all receipts and disbursements of the Trust
Account;


 


(i)                                     Until
such time as the Trustee shall have disbursed an aggregate amount equal to
$3,000,000 to the Company (net of any expenses of the Trustee payable pursuant
to Section 3(c) and any income or other tax obligations relating to
the income from the Property in the Trust, the amount of such tax obligations
as determined by the Company), the Trustee shall disburse to the Company, on
the first business day of each calendar month, in cash, the amount of any
interest income earned on the Trust Account. Following such time as the Trustee
shall have disbursed an amount equal to $3,000,000 to the Company (net of any
expenses of the Trustee payable pursuant Section 3(c) and any income
or other tax obligations relating to the income from the Property in the Trust,
the amount of such tax obligations as determined by the Company), if there is
any income or other tax obligation relating to the income from the Property in
the Trust Account as determined by the Company, then, from time to time, at the
written instruction of the Company, the Trustee shall promptly to the extent
there is not sufficient cash in the Trust Account to pay such tax obligation,
liquidate such assets held in the Trust Account as shall be designated by the
Company in writing, and disburse to the Company by wire transfer, out of the
Property in the Trust Account, the amount indicated by the Company as owing in
respect of such income tax obligation; and


 


2

















 


(j)                                     Commence
liquidation of the Trust Account only upon receipt of and only in accordance
with the terms of a letter (the “Termination Letter”), in a form substantially
similar to that attached hereto as either Exhibit A or Exhibit B
as the case by be, signed on behalf of the Company, and complete the
liquidation of the Trust Account and distribute the Property in the Trust
Account only as directed in the Termination Letter and the other documents
referred to therein. The Trustee shall provide the Underwriters with a copy of
any Termination Letter and/or any other correspondence that it receives with
respect to any proposed withdrawal from the Trust Account promptly after it
receives the same.


 


2.                                       Limited Distributions Of Income From Trust Account.


 


Each of the parties hereto hereby acknowledge and
agree that no distributions from the Trust Account shall be permitted except in
accordance with Sections 1(i) and 1(j) hereof.


 


3.                                       Agreements and Covenants of the Company. The Company hereby agrees and covenants to:


 


(a)                                  Give
all instructions to the Trustee hereunder in writing, signed by an officer of
the Company. In addition, except with respect to its duties under Sections 1(i) and
1(j) above, the Trustee shall be entitled to rely on, and shall be protected in
relying on, any verbal or telephonic advice or instruction which it in good
faith believes to be given by any one of the persons authorized above to give
written instructions, provided that the Company shall promptly confirm such
instructions in writing;


 


(b)                                 Subject
to the provisions of Section 6 hereof, hold the Trustee harmless and
indemnify the Trustee from and against, any and all expenses, including
reasonable counsel fees and disbursements, or loss suffered by the Trustee in
connection with any action, suit or other proceeding brought against the
Trustee involving any claim, or in connection with any claim or demand which in
any way arises out of or relates to this Agreement, the services of the Trustee
hereunder, or the Property or any income earned from investment of the
Property, except for expenses and losses resulting from the Trustee’s gross
negligence or willful misconduct. Promptly after the receipt by the Trustee of
notice of demand or claim or the commencement of any action, suit or
proceeding, pursuant to which the Trustee intends to seek indemnification under
this paragraph, it shall notify the Company in writing of such claim and the
nature, basis and amount of such claim to the extent then known (hereinafter
referred to as the “Indemnified Claim”). The Company shall have the
right to conduct and manage the defense against such Indemnified Claim,
provided, that the Company shall obtain the consent of the Trustee with respect
to the selection of counsel, which consent shall not be unreasonably withheld. The
Trustee shall be entitled to participate in such action with its own counsel;


 


(c)                                  Pay
the Trustee an initial acceptance fee, an annual fee and a transaction
processing fee for each disbursement made pursuant to Section 1(i) as
set forth on Schedule A hereto, which fees shall be subject to
modification by the parties from time to time. It is expressly understood that
the Property shall not be used to pay such fees and further agreed that said
transaction processing fees shall be deducted by the Trustee from the
disbursements made to the Company pursuant to Section 1(i). The Company
shall pay the Trustee the initial acceptance


 


3

















 


fee and first year’s fee at the
consummation of the IPO and thereafter on the anniversary of the Effective Date.
The Trustee shall refund to the Company the annual fee (on a pro rata basis)
with respect to any period after the liquidation of the Trust Fund. The Company
shall not be responsible for any other fees or charges of the Trustee except as
set forth in this Section 3(c) and as may be provided in Section 3(b) hereof
(it being expressly understood that the Property shall not be used to make any
payments to the Trustee under such Sections);


 


(d)                                 Provide
to the Trustee any letter of intent, agreement in principle or definitive
agreement that is executed prior to [        ,
              ]
in connection with a business combination as described in and contemplated by
the Registration Statement ( a “Business Combination”); and


 


(e)                                  In
connection with any vote of the Company’s stockholders regarding a Business
Combination, provide to the Trustee an affidavit or certificate of a firm
regularly engaged in the business of soliciting proxies and tabulating
stockholder votes (which firm may be the Trustee) verifying the vote of
the Company’s stockholders regarding such Business Combination.


 


4.                                       Limitations of Liability. The Trustee shall have no responsibility or
liability:


 


(a)                                  to
take any action with respect to the Property, other than as directed in Section 1
hereof and the Trustee shall have no liability to any party except for
liability arising out of its own gross negligence or willful misconduct;


 


(b)                                 to
institute any proceeding for the collection of any principal and income arising
from, or institute, appear in or defend any proceeding of any kind with respect
to, any of the Property unless and until it shall have received written
instructions from the Company given as provided herein to do so and the Company
shall have advanced or guaranteed to it funds sufficient to pay any expenses
incident thereto;


 


(c)                                  to
change the investment of any Property, other than in compliance with Section 1(c);


 


(d)                                 to
refund any depreciation in principal of any Property;


 


(e)                                  to
assume that the authority of any person designated by the Company to give
instructions hereunder shall not be continuing unless provided otherwise in
such designation, or unless the Company shall have delivered a written
revocation of such authority to the Trustee;


 


(f)                                    to
the other parties hereto or to anyone else for any action taken or omitted by
it, or any action suffered by it to be taken or omitted, in good faith and in
the exercise of its own best judgment, except for its gross negligence or
willful misconduct. The Trustee may rely conclusively and shall be
protected in acting upon any order, judgment, instruction, notice, demand,
certificate, opinion or advice of counsel (including counsel chosen by the
Trustee), statement, instrument, report or other paper or document (not only as
to its due execution and the validity and effectiveness of its provisions, but
also as to the truth and acceptability of any information therein contained)
which is believed by the Trustee, in good faith, to be genuine and


 


4

















 


to be signed or presented by
the proper person or persons. The Trustee shall not be bound by any notice or
demand, or any waiver, modification, termination or rescission of this
agreement or any of the terms hereof, unless evidenced by a written instrument
delivered to the Trustee signed by the proper party or parties and, if the
duties or rights of the Trustee are affected, unless it shall give its prior
written consent thereto;


 


(g)                                 in
respect of the correctness of the information set forth in the Registration
Statement or to confirm or assure that any acquisition made by the Company or
any other action taken by it is as contemplated by the Registration Statement;


 


5.                                       Termination. This Agreement shall terminate as follows:


 


(a)                                  If
the Trustee gives written notice to the Company that it desires to resign under
this Agreement, the Company shall use its reasonable efforts to locate a
successor trustee. At such time that the Company notifies the Trustee that a
successor trustee has been appointed by the Company and has agreed to become
subject to the terms of this Agreement, the Trustee shall transfer the
management of the Trust Account to the successor trustee, including but not
limited to the transfer of copies of the reports and statements relating to the
Trust Account, whereupon this Agreement shall terminate; provided, however,
that, in the event that the Company does not locate a successor trustee within
ninety days of receipt of the resignation notice from the Trustee, the Trustee may submit
an application to have the Property deposited with the United States District
Court for the Southern District of New York and upon such deposit, the Trustee
shall be immune from any liability whatsoever that arises due to any actions or
omissions to act by any party after such deposit; or


 


(b)                                 At
such time that the Trustee has completed the liquidation of the Trust Account
in accordance with the provisions of Section 1(j) hereof, and distributed
the Property in accordance with the provisions of the Termination Letter, this
Agreement shall terminate.


 


6.                                       Waiver.


 


Notwithstanding anything herein to the
contrary, the Trustee hereby waives any
and all right, title, interest or claim of any kind (“Claim”) in or
to any distribution of the Trust Account, and hereby agrees not to seek
recourse, reimbursement, payment or satisfaction for any Claim against the
Trust Account for any reason whatsoever.


 


7.                                       Miscellaneous.


 


(a)                                  The
Company and the Trustee each acknowledge and agree that the Trustee will follow
the security procedures set forth below with respect to funds transferred from
the Trust Account. Upon receipt of written instructions, the Trustee will
confirm such instructions with an Authorized Individual at an Authorized
Telephone Number listed on the attached Exhibit C. The Company and
the Trustee will each restrict access to confidential information relating to
such security procedures to authorized persons. Each party must notify the other
party immediately if it has reason to believe unauthorized persons may have
obtained access to such information, or of any change in its authorized
personnel. In executing funds transfers, the Trustee will rely upon account
numbers or other identifying numbers of a beneficiary, beneficiary’s bank or
intermediary bank, rather than names. The Trustee shall not be


 


5

















 


liable for any loss, liability
or expense resulting from any error in an account number or other identifying
number, provided it has accurately transmitted the numbers so provided to it.


 


(b)                                 This
Agreement shall be governed by and construed and enforced in accordance with
the laws of the State of New York, without giving effect to the conflicts of
law principles thereof. It may be executed in one or more
counterparts, each of which shall constitute an original, and together shall
constitute one and the same instrument.


 


(c)                                  This
Agreement contains the entire agreement and understanding of the parties hereto
with respect to the subject matter hereof. The parties hereto may change,
waive, amend or modify any provision contained herein that may be
defective or inconsistent with any other provision contained herein only upon
the written consent of each of the parties hereto; provided that such action
shall not materially adversely affect the interests of the Public Stockholders.
As to any claim, cross-claim or counterclaim in any way relating to this
Agreement, each party waives the right to trial by jury.


 


(d)                                 The
parties hereto consent to the jurisdiction and venue of any state or federal
court located in the City of New York for purposes of resolving any disputes
hereunder.


 


(e)                                  Any
notice, consent or request to be given in connection with any of the terms or
provisions of this Agreement shall be in writing and shall be sent by express
mail or similar private courier service, by certified mail (return receipt
requested), by hand delivery or by facsimile transmission:


 


if to the Trustee, to:


 


Continental Stock Transfer & Trust Company

17 Battery Place

8th Floor

New York, New York  10004

Attn: [                            ]

Fax: [                    ]


 


if to the Company, to:


 


Information Services Group, Inc.


Four Stamford Plaza


107 Elm Street

Stamford, CT 06902


Attn: Michael P. Connors

Fax:


 


with copies to:


 


Information Services Group, Inc.

Four Stamford Plaza


107 Elm Street

Stamford, CT 06902


 


6

















 


Attn:  Earl H.
Doppelt

Fax:


 


and


 


Kaye Scholer LLP

425 Park Avenue

New York, NY  10022

Attn: Emanuel S. Cherney, Esq.

Fax: (212) 836-8689


 


in either case with a copy on behalf of the
Underwriters to:


 


Deutsche Bank Securities Inc.

60 Wall Street NYC 60-1001

New York, NY  10005

Attn: Syndicate Manager

Fax: (212) 797-9344


 


Morgan Joseph & Co., Inc.

[                                ]

[                                ]

[                                ]


 


Lazard Capital Markets, LLC

[                                ]

[                                ]

[                                ]


 


with a copy to:


 


Kramer Levin Naftalis & Frankel LLP

1177 Avenue of the Americas

New York, NY  10036

Attn: Christopher S. Auguste, Esq.

Fax: (212) 715-8000


 


(f)                                    This
Agreement may not be assigned by the Trustee without the prior written consent
of the Company.


 


(g)                                 Each
of the Trustee and the Company hereby represents that it has the full right and
power and has been duly authorized to enter into this Agreement and to perform its
respective obligations as contemplated hereunder. The Trustee acknowledges and
agrees that it shall not make any claims or proceed against the Trust Account,
including by way of set-off, and shall not be entitled to any part of the
Property under any circumstance.


 


7

















 


(h)                                 The
Trustee hereby consents to the inclusion of Continental Stock Transfer &
Trust Company in the Registration Statement and other materials relating to the
IPO.


 


(i)                                     The
Underwriters shall be third party beneficiaries of this Agreement and this
Agreement may not be modified or changed without the prior written consent
of Deutsche Bank Securities Inc.


 


[Signature page follows]


 


8

















 


IN WITNESS WHEREOF, the parties have duly executed
this Investment Management Trust Agreement as of the date first written above.


 


	
   

  	
  CONTINENTAL STOCK
  TRANSFER & TRUST

  COMPANY, as Trustee

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Name:

  
	
   

  	
   

  	
  Title:

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  INFORMATION SERVICES
  GROUP, INC.

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Name:

  	
  Michael P. Connors

  
	
   

  	
   

  	
  Title:

  	
  Chairman and

  
	
   

  	
   

  	
   

  	
  Chief Executive Officer

  
					



 


9

















 


EXHIBIT A


 


[LETTERHEAD OF COMPANY]


 


[INSERT DATE]


 


Continental Stock Transfer & Trust Company

17 Battery Place

8th Floor

New York, New York  10004

Attn: [                              ]


 


Re:                               Trust
Account No. [                      ]
Termination Letter


 


Gentlemen:


 


Pursuant to Section 1(j) of the Investment
Management Trust Agreement between Information Services Group, Inc. (the “Company”)
and Continental Stock Transfer & Trust Company (the “Trustee”),
dated as of                           ,
2007 (the “Trust Agreement”), this is to advise you that the Company has
entered into an agreement (“Business Agreement”) with                                     
(the “Target Business”) to consummate a business combination with Target
Business (a “Business Combination”) on or about [INSERT DATE]. The
Company shall notify you at least 48 hours in advance of the actual date of the
consummation of the Business Combination (the “Consummation Date”). Capitalized
terms used but not otherwise defined herein shall have the meaning ascribed to
such terms in the Trust Agreement.


 


Pursuant to Section 3(e) of the Trust
Agreement, we are providing you with [an affidavit] [a certificate] of                                     ,
which verifies the vote of the Company’s stockholders in connection with the
Business Combination. In accordance with the terms of the Trust Agreement, we
hereby authorize you to commence liquidation of the Trust Account to the effect
that, on the Consummation Date, all of the funds held in the Trust Account will
be immediately available for transfer to the account or accounts that the
Company shall direct in writing on the Consummation Date.


 


On the Consummation Date (i) counsel for the Company
shall deliver to you written notification that the Business Combination has
been consummated and (ii) the Company shall deliver to you written
instructions with respect to the transfer of the funds held in the Trust
Account (the “Instruction Letter”). You are hereby directed and
authorized to transfer the funds held in the Trust Account immediately upon
your receipt of the counsel’s letter and the Instruction Letter, in accordance
with the terms of the Instruction Letter. In the event that certain deposits
held in the Trust Account may not be liquidated by the Consummation Date
without penalty, you will notify the Company of the same and the Company shall
direct you as to whether such funds should remain in the Trust Account and be
distributed after the Consummation Date to the Company or, with respect to the
Deferred Discount, to the Underwriters. Upon the distribution of all the funds
in the Trust Account pursuant to the terms hereof, the Trust Agreement shall
automatically terminated and cease to have any further force or effect.


 

















 


In the event that the Business Combination is not
consummated on the Consummation Date described in the notice thereof and we
have not notified you on or before the original Consummation Date of a new
Consummation Date, then the funds held in the Trust Account shall be reinvested
as provided in the Trust Agreement on the business day immediately following
the Consummation Date as set forth in the notice.


 


	
   

  	
  Very truly yours,

  
	
   

  	
   

  
	
   

  	
  INFORMATION SERVICES
  GROUP, INC.

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Name:

  
	
   

  	
   

  	
  Title:

  



 

















 


EXHIBIT B


 


[LETTERHEAD OF COMPANY]


 


[INSERT DATE]


 


Continental Stock Transfer & Trust Company

17 Battery Place

8th Floor

New York, New York  10004

Attn: [                                ]


 


Re:                               Trust
Account No. [                  ]
Termination Letter


 


Gentlemen:


 


Pursuant to paragraph 1(j) of the Investment
Management Trust Agreement between Information Services Group, Inc. (the “Company”)
and Continental Stock Transfer & Trust Company (the “Trustee”), dated
as of                           ,
2007 (the “Trust Agreement”), this is to advise you that the Company has
been dissolved due to the Company’s inability to effect a Business Combination
within the time frame specified in the Company’s prospectus relating to its
IPO.


 


Attached hereto is a certified copy of the Certificate
of Dissolution as filed with the Delaware Secretary of State. Defined terms
used but not otherwise defined herein shall have the meaning ascribed to such
terms in the Trust Agreement.


 


In accordance with the terms of the Trust Agreement,
we hereby authorize you to commence liquidation of the Trust Account. You will
notify the Company and [                              ]
(the “Designated Paying Agent”) in writing as to when all of the funds
in the Trust Account will be available for immediate transfer (the “Transfer
Date”). The Designated Paying Agent shall thereafter notify you as to the
account or accounts of the Designated Paying Agent that the funds in the Trust
Account should be transferred to on the Transfer Date so that the Designated
Paying Agent may commence distribution of such funds in accordance with
the Company’s instructions. You shall have no obligation to oversee the
Designated Paying Agent’s distribution of the funds. Upon the payment to the
Designated Paying Agent of all the funds in the Trust Account, the Trust
Agreement shall terminate in accordance with the terms thereof.


 


	
   

  	
  Very truly yours,

  
	
   

  	
   

  
	
   

  	
  INFORMATION SERVICES
  GROUP, INC.

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Name:

  
	
   

  	
   

  	
  Title:

  



 

















 


EXHIBIT C


 


AUTHORIZED INDIVIDUAL(S) AND
TELEPHONE NUMBERS


 


AUTHORIZED FOR TELEPHONE
CALL BACK


 


COMPANY:                              Information
Services Group, Inc.

Four Stamford Plaza


107 Elm Street

Stamford, CT 06902

Attn: Michael P. Connors

Telephone: (203) 517-3100


 


Information
Services Group, Inc.

Four Stamford Plaza


107 Elm Street

Stamford, CT 06902

Attn: Earl H. Doppelt

Telephone: (203) 517-3100


 


TRUSTEE:                                       Continental
Stock Transfer & Trust Company

17 Battery Place

8th Floor

New York, New York  10004

Attn: [                                ]

Telephone: [                      ]


 

















 


SCHEDULE A


 


Schedule of fees pursuant to Section 3(c) of
Investment Management Trust Agreement between Information Services Group, Inc.
and Continental Stock Transfer & Trust Company


 


	
  FEE ITEM

  	
   

  	
  TIME AND METHOD OF PAYMENT

  	
   

  	
  AMOUNT

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Initial
  acceptance fee

  	
   

  	
  Initial closing
  of IPO by wire transfer

  	
   

  	
  $[        ]

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Annual fee

  	
   

  	
  First year,
  initial closing of IPO by wire transfer; thereafter on the anniversary of the
  effective date of the IPO by wire transfer or check

  	
   

  	
  $[        ]

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Transaction
  processing fee for disbursements to Company under Section 1(i)

  	
   

  	
  Deduction by
  Trustee from disbursement made to Company under Section 1(i)

  	
   

  	
  $[        ]

  



 


 


	
   

  	
  Agreed:

  	
   

  
	
   

  	
   

  	
   

  
	
  Dated:
  [                        
        , 200  ]

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Information Services
  Group, Inc.

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Authorized
  Officer

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Continental Stock
  Transfer & Trust Co.

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
   

  	
  Authorized
  Officer