10



THIS NOTE AND THE COMMON SHARES ISSUABLE UPON CONVERSION OF THIS NOTE HAVE NOT
BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR ANY STATE
SECURITIES LAWS. THIS NOTE AND THE COMMON SHARES ISSUABLE UPON CONVERSION OF
THIS NOTE MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED OR HYPOTHECATED IN THE
ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT AS TO THIS NOTE UNDER SAID ACT
AND ANY APPLICABLE STATES SECURITIES LAWS OR AN OPINION OF COUNSEL REASONABLY
SATISFACTORY TO VERIDIUM CORPORATION THAT SUCH REGISTRATION IS NOT REQUIRED.


                   SECURED CONVERTIBLE MINIMUM BORROWING NOTE



     FOR VALUE  RECEIVED,  VERIDIUM  CORPORATION  a  Delaware  corporation  (the
"Borrower") promises to pay to LAURUS MASTER FUND, LTD., c/o Ironshore Corporate
Services Ltd., P.O. Box 1234 G.T.,  Queensgate House, South Church Street, Grand
Cayman,  Cayman  Islands,  Fax:  345-949-9877  (the  "Holder") or its registered
assigns,  on  order,  the  sum of  ONE  MILLION  DOLLARS  ($1,000,000),  or,  if
different,  the  aggregate  principal  amount  of all  "Loans"  (as such term is
defined in the Security Agreement referred to below),  together with any accrued
and unpaid interest hereon, on March __, 2007 (the "Maturity Date").

     Capitalized  terms used herein without  definition  shall have the meanings
ascribed to such terms in the Security Agreement between Borrower and the Holder
dated as of March __, 2004 (as amended,  modified and supplemented  from time to
time, the "Security Agreement").

The following terms shall apply to this Minimum Borrowing Note (the "Note"):

                                   ARTICLE I
                                    INTEREST

     1.1  Interest  Rate and  Payments.  Subject to Sections 5.3 and 6.7 hereof,
interest  payable  on this Note  shall  accrue at a rate per annum  equal to the
"prime rate"  published in The Wall Street Journal from time to time,  plus five
(5%) (the  "Contract  Rate").  The Prime Rate shall be increased or decreased as
the case may be for each  increase  or  decrease  in the Prime Rate in an amount
equal to such  increase  or  decrease  in the  Prime  Rate;  each  change  to be
effective as of the day of the change in such rate in accordance  with the terms
of the Security Agreement.  Subject to the immediately  following sentence,  the
Contract Rate shall not be less than nine percent (9%).  The Contract Rate shall
be adjusted as follows:  if (i) the Company shall have  registered the shares of
the  Company's  common stock  underlying  the  conversion  of this Note and that
certain  warrant  issued  to  Holder of even  date  herewith  on a  registration
statement declared effective by the Securities Exchange Commission, and (ii) the
volume weighted average price of the Common Stock as reported by Bloomberg, L.P.
on the  principal  market  for  any of the ten  (10)  trading  days  immediately
preceding a Interest  Payment Date (defined  below) exceeds the then  applicable
Fixed  Conversion  Price by twenty five percent (25%), the Contract Rate for the
succeeding  calendar month shall  automatically  be reduced by twenty five basis
points (25 b.p.) for such period.  In no event shall the  Contract  Rate be less
than 0.00%.  Interest shall be payable  monthly in arrears  commencing on May 1,
2004 and on the first day of each consecutive calendar month thereafter,  (each,
an "Interest Payment Date").

                                   ARTICLE II
            ADVANCES, BORROWER CONVERSION RIGHTS, PAYMENTS UNDER NOTE

     2.1. Mechanics of Advances.  All Loans evidenced by this Note shall be made
in  accordance  with the terms and  provisions of the Security  Agreement.  2.2.
Fixed Conversion Price. For purposes hereof,  subject to Section 3.5 hereof, the
"Fixed Conversion Price" means $0.43.

     2.3. No Effective  Registration.  Notwithstanding  anything to the contrary
herein,  the Borrower shall be prohibited from exercising its right to repay any
amount  hereunder  in shares  of Common  Stock if at any time from the Call Date
(defined  below) for such  payment  through the date upon which such  payment is
made by delivery of certificates for shares of Common Stock there fails to exist
an effective  current  Registration  Statement  (as defined in the  Registration
Rights  Agreement)  covering the shares of Common  Stock to be issued,  or if an
Event of Default hereunder exists and is continuing,  unless such requirement is
otherwise  waived in writing  by the Holder in whole or in part at the  Holder's
option.

     2.4. Optional  Payments in Common Stock.  Subject to Section 2.2 hereof, if
the Company elects to pay interest or prepay  principal and the average  closing
price of the Common  Stock on the  Principal  Market is greater than 110% of the
Fixed  Conversion  Price for a period of at least five (5)  consecutive  trading
days,  then the  Borrower  may, at its sole option,  provide the Holder  written
notice (a "Call Notice")  requiring the conversion at the Fixed Conversion Price
of all or a  portion  of the  outstanding  interest  or  principal  of this Note
(subject to compliance with Section 2.3 and 3.2,  together with accrued interest
on the amount being  prepaid,  as of the date set forth in such Call Notice (the
"Call  Date").  The Call Date shall be at least ten (10) trading days  following
the date of the Call Notice.  On the Call Date the Borrower shall deliver to the
Holder certificates evidencing the shares of Common Stock issued in satisfaction
of the principal and/or interest being retired.  Notwithstanding  the foregoing,
the  Borrower's  right to issue shares of Common Stock in payment of obligations
under this Note shall be subject to the limitation  that the number of shares of
Common Stock issued in  connection  with any Call Notice shall not exceed 25% of
the aggregate dollar trading volume of the Common Stock for the ten (10) trading
days  immediately  preceding  the Call  Date  (as such  volume  is  reported  by
Bloomberg,  L.P. If the price of the Common  Stock falls below 110% of the Fixed
Conversion  Price during the ten (10) trading day period  immediately  preceding
the Call Date, then the Holder will then be required to convert only such amount
of the Note as shall equal twenty five  percent  (25%) of the  aggregate  dollar
trading volume (as such volume is reported by Bloomberg  L.P.) for each day that
the Common  Stock has  exceeded  110% of the then  applicable  Fixed  Conversion
Price. The Borrower shall not be permitted to give the Holder more than one Call
Notice under this Note during any 10-day period.

     2.5  Optional  Redemption  in Cash.  The  Borrower  will have the option of
prepaying this Note in full (but not in part) in cash,  ("Optional  Redemption")
by paying to the  Holder a sum of money  equal to one  hundred  fifteen  percent
(115%) of the  principal  amount of this Note  together  with accrued but unpaid
interest  thereon  and any and all other  sums due,  accrued  or  payable to the
Holder  arising  under this  Note,  the  Security  Agreement,  or any  Ancillary
Agreement  (as defined in the  Security  Agreement)  (the  "Redemption  Amount")
outstanding on the day written notice of redemption (the "Notice of Redemption")
is given to the Holder. The Notice of Redemption shall specify the date for such
Optional  Redemption (the  "Redemption  Payment Date") which date shall be seven
(7) days after the date of the Notice of Redemption (the "Redemption Period"). A
Notice of Redemption  shall not be effective with respect to any portion of this
Note for which the Holder has a pending  election to convert pursuant to Section
3.1, or for conversions elected to be made by the Holder pursuant to Section 3.1
during the Redemption  Period.  The Redemption  Amount shall be determined as if
such Holder's conversion  elections had been completed  immediately prior to the
date of the Notice of Redemption. On the Redemption Payment Date, the Redemption
Amount must be paid in good funds to the Holder. In the event the Borrower fails
to pay  the  Redemption  Amount  on  the  Redemption  Payment  Date,  then  such
Redemption Notice will be null and void.

                                  ARTICLE III
                           HOLDER'S CONVERSION RIGHTS

     3.1.  Optional  Conversion.  Subject to the terms of this  Article III, the
Holder  shall  have the  right,  but not the  obligation,  at any time until the
Maturity  Date, or thereafter  during an Event of Default (as defined in Article
V), and, subject to the limitations set forth in Section 3.2 hereof,  to convert
all or any portion of the outstanding  Principal  Amount and/or accrued interest
and fees due and payable into fully paid and nonassessable  shares of the Common
Stock at the Fixed  Conversion  Price.  The shares of Common  Stock to be issued
upon such  conversion are herein  referred to as the  "Conversion  Shares."

     3.2. Conversion  Limitation.  Notwithstanding  anything contained herein to
the contrary,  the Holder shall not be entitled to convert pursuant to the terms
of this Note an amount that would be convertible  into that number of Conversion
Shares which would exceed the difference  between the number of shares of Common
Stock  beneficially  owned by such Holder or issuable  upon exercise of warrants
held by such Holder and 4.99% of the  outstanding  shares of Common Stock of the
Borrower.  For the purposes of the immediately  preceding  sentence,  beneficial
ownership  shall be determined in accordance  with Section 13(d) of the Exchange
Act and Regulation 13d-3 thereunder.  The Conversion Shares limitation described
in this Section 3.2 shall automatically  become null and void without any notice
to Borrower upon the occurrence and during the continuance beyond any applicable
grace  period  of an Event  of  Default,  or upon 75 days  prior  notice  to the
Borrower.

     3.3. Mechanics of Holder's Conversion.  In the event that the Holder elects
to convert  this Note into Common  Stock,  the Holder  shall give notice of such
election by delivering an executed and completed  notice of conversion  ("Notice
of  Conversion")  to the Borrower and such Notice of Conversion  shall provide a
breakdown in reasonable  detail of the Principal  Amount,  accrued  interest and
fees that are being converted.  On each Conversion Date (as hereinafter defined)
and in  accordance  with its Notice of  Conversion,  the  Holder  shall make the
appropriate  reduction to the  Principal  Amount,  accrued  interest and fees as
entered in its records and shall provide  written notice thereof to the Borrower
within two (2) business  days after the  Conversion  Date.  Each date on which a
Notice of  Conversion  is delivered or  telecopied to the Borrower in accordance
with the provisions  hereof shall be deemed a Conversion  Date (the  "Conversion
Date").  A form of Notice of  Conversion to be employed by the Holder is annexed
hereto as Exhibit A.  Pursuant  to the terms of the  Notice of  Conversion,  the
Borrower will issue instructions to the transfer agent accompanied by an opinion
of counsel  within one (1)  business day of the date of the delivery to Borrower
of the Notice of Conversion  and shall cause the transfer  agent to transmit the
certificates  representing the Conversion  Shares to the Holder by crediting the
account of the Holder's  designated broker with the Depository Trust Corporation
("DTC") through its Deposit  Withdrawal Agent Commission  ("DWAC") system within
three  (3)  business  days  after  receipt  by the  Borrower  of the  Notice  of
Conversion (the "Delivery  Date"). In the case of the exercise of the conversion
rights set forth herein the  conversion  privilege  shall be deemed to have been
exercised  and the  Conversion  Shares  issuable upon such  conversion  shall be
deemed to have been  issued  upon the date of  receipt  by the  Borrower  of the
Notice of Conversion. The Holder shall be treated for all purposes as the record
holder of such Common  Stock,  unless the Holder  provides the Borrower  written
instructions to the contrary.

     3.4. Late Payments.  The Borrower  understands that a delay in the delivery
of the shares of Common  Stock in the form  required  pursuant  to this  Article
beyond the  Delivery  Date  could  result in  economic  loss to the  Holder.  As
compensation  to the  Holder  for such  loss,  the  Borrower  agrees to pay late
payments to the Holder for late  issuance  of such  shares in the form  required
pursuant to this Article III upon conversion of the Note, in the amount equal to
$500 per  business  day after the  Delivery  Date.  The  Borrower  shall pay any
payments incurred under this Section in immediately available funds upon demand.

     3.5. Adjustment Provisions.  The Fixed Conversion Price and number and kind
of shares or other securities to be issued upon conversion  determined  pursuant
to  Section  2.2  shall be  subject  to  adjustment  from  time to time upon the
happening of certain events while this conversion right remains outstanding,  as
follows:

          A.  Reclassification,  etc.  If the  Borrower  at any time  shall,  by
     reclassification  or otherwise,  change the Common Stock into the same or a
     different  number of securities  of any class or classes,  this Note, as to
     the unpaid Principal Amount and accrued interest thereon,  shall thereafter
     be deemed to evidence  the right to  purchase  an  adjusted  number of such
     securities and kind of securities as would have been issuable as the result
     of such change with respect to the Common Stock  immediately  prior to such
     reclassification  or  other  change.

          B. Stock Splits,  Combinations and Dividends.  If the shares of Common
     Stock are subdivided or combined into a greater or smaller number of shares
     of Common Stock,  or if a dividend is paid on the Common Stock in shares of
     Common Stock, the Fixed Conversion Price shall be  proportionately  reduced
     in case of  subdivision  of shares  or stock  dividend  or  proportionately
     increased in the case of  combination  of shares,  in each such case by the
     ratio  which the  total  number  of  shares  of  Common  Stock  outstanding
     immediately  after such event bears to the total number of shares of Common
     Stock  outstanding  immediately  prior to such event.

          C. Share Issuances.  Subject to the provisions of this Section 3.5, if
     the Borrower shall at any time prior to the conversion or repayment in full
     of the Principal  Amount issue any shares of Common Stock to a person other
     than the Holder  (except (i)  pursuant to  Subsections  A or B above;  (ii)
     pursuant  to  options,  warrants,  or other  obligations  to  issue  shares
     outstanding on the date hereof as disclosed to Holder in writing;  or (iii)
     pursuant to options that may be issued under any employee  incentive  stock
     option and/or any qualified  stock option plan adopted by the Borrower) for
     a  consideration  per  share  (the  "Offer  Price")  less  than  the  Fixed
     Conversion  Price in  effect at the time of such  issuance,  then the Fixed
     Conversion Price shall be immediately  reset to such lower Offer Price. For
     purposes hereof,  the issuance of any security of the Borrower  convertible
     into or  exercisable  or  exchangeable  for Common Stock shall result in an
     adjustment  to the Fixed  Conversion  Price at the time of issuance of such
     securities.

          D.  Computation  of  Consideration.  For  purposes of any  computation
     respecting  consideration  received  pursuant to  Subsection  C above,  the
     following shall apply:

               (a) in the case of the  issuance  of shares  of Common  Stock for
          cash,  the  consideration  shall be the amount of such cash,  provided
          that in no case  shall  any  deduction  be made  for any  commissions,
          discounts  or  other  expenses   incurred  by  the  Borrower  for  any
          underwriting of the issue or otherwise in connection therewith;

               (b) in the case of the  issuance of shares of Common  Stock for a
          consideration  in whole or in part other than cash, the  consideration
          other than cash shall be deemed to be the fair market value thereof as
          determined  in good faith by the Board of  Directors  of the  Borrower
          (irrespective of the accounting  treatment thereof);  and

               (c) Upon any such exercise, the aggregate  consideration received
          for such securities shall be deemed to be the  consideration  received
          by  the  Borrower  for  the  issuance  of  such  securities  plus  the
          additional  minimum  consideration,  if  any,  to be  received  by the
          Borrower upon the conversion or exchange thereof (the consideration in
          each case to be  determined  in the same manner as provided in clauses
          (a) and (b) of this  Subsection  (D)).

     3.6. Reservation of Shares.  During the period the conversion right exists,
the  Borrower  will  reserve from its  authorized  and  unissued  Common Stock a
sufficient number of shares to provide for the issuance of Common Stock upon the
full conversion of this Note. The Borrower  represents that upon issuance,  such
shares  will be duly and  validly  issued,  fully paid and  non-assessable.  The
Borrower  agrees that its issuance of this Note shall  constitute full authority
to its officers,  agents,  and transfer  agents who are charged with the duty of
executing  and issuing  stock  certificates  to execute and issue the  necessary
certificates  for shares of Common Stock upon the conversion of this Note.

     3.7.  Registration  Rights. The Holder has been granted registration rights
with respect to the shares of Common Stock issuable upon conversion of this Note
as more  fully  set  forth in a  Registration  Rights  Agreement  dated the date
hereof.

                                   ARTICLE IV
                               EVENTS OF DEFAULT

     The  occurrence  of any of the  following  events  is an Event  of  Default
("Event of Default"):

     4.1.  Failure to Pay Principal,  Interest or other Fees. The Borrower fails
to pay when due any  installment of principal,  interest or other fees hereon or
on any other promissory note issued pursuant to the Security Agreement, when due
in accordance with the terms of such note.

     4.2. Breach of Covenant.  The Borrower  breaches any covenant or other term
or condition of this Note in any material respect and such breach, if subject to
cure, continues for a period of thirty (30) days after the occurrence thereof.

     4.3. Breach of Representations and Warranties.  Any material representation
or warranty of the Borrower made herein,  or the Security  Agreement,  or in any
Ancillary Agreement shall be materially false or misleading.

     4.4.  Stop  Trade.  An SEC stop trade  order or  Principal  Market  trading
suspension  of the Common Stock shall be in effect for 5  consecutive  days or 5
days during a period of 10 consecutive days, excluding in all cases a suspension
of all trading on a Principal Market,  provided that the Borrower shall not have
been able to cure such trading  suspension  within 30 days of the notice thereof
or list the Common  Stock on  another  Principal  Market  within 60 days of such
notice.  The "Principal  Market" for the Common Stock shall include the NASD OTC
Bulletin Board, NASDAQ SmallCap Market, NASDAQ National Market System,  American
Stock Exchange, or New York Stock Exchange (whichever of the foregoing is at the
time the  principal  trading  exchange or market for the Common  Stock),  or any
securities exchange or other securities market on which the Common Stock is then
being listed or traded.

     4.5. Default Under Related Agreement. The occurrence of an Event of Default
under and as defined in the Security Agreement and/or the Ancillary Agreements.

     4.6 Failure to Deliver  Common Stock or  Replacement  Note.  The Borrower's
failure to timely deliver Common Stock to the Holder pursuant to and in the form
required by this Note, and Section 9 of the Security Agreement,  or if required,
a replacement  Note if such failure to timely  deliver Common Stock shall not be
cured within two (2) business days or such failure to deliver a replacement Note
is not cured within seven (7) business days.

     4.7 Payment Grace Period. The Borrower shall have a three (3)
business day grace period to pay any monetary amounts due under this Note or the
Security Agreement or any Ancillary Agreements, after which grace period a
default interest rate of two and one half percent (2.5%) per annum above the
then applicable interest rate hereunder shall apply to the monetary amounts due.

                                   ARTICLE V
                                DEFAULT PAYMENTS

     5.1. Default  Payment.  If an Event of Default occurs,  the Holder,  at its
option,  may elect,  in addition to all rights and  remedies of Holder under the
Security Agreement and all obligations of Borrower under the Security Agreement,
to require  the  Borrower to make a Default  Payment  ("Default  Payment").  The
Default  Payment shall be the  outstanding  principal  amount of the Note,  plus
accrued but unpaid interest, all other fees then remaining unpaid, and all other
amounts payable hereunder.

     5.2.  Default  Payment Date and Default Notice Period.  The Default Payment
shall be due and payable on the fifth  business day after an Event of Default as
defined in Article IV ("Default  Payment  Date") has occurred and is  continuing
beyond any  applicable  grace period.  The period  between date upon which of an
Event of Default has  occurred and is  continuing  beyond any  applicable  grace
period and the Default Payment Date shall be the "Default Period." If during the
Default  Period,  the Borrower cures the Event of Default,  the Event of Default
will no longer exist and any  additional  rights the Holder had triggered by the
occurrence and  continuance of an Event of Default will no longer exist.  If the
Event of Default is not cured  during the  Default  Notice  Period,  all amounts
payable  hereunder  shall be due and payable on the Default  Payment  Date,  all
without further  demand,  presentment or notice,  or grace period,  all of which
hereby  are  expressly  waived.

     5.3.  Default  Interest  Rate.  Following  the  occurrence  and  during the
continuance of an Event of Default, interest on this Note shall automatically be
increased  to one and one half  percent  (1.5%) per month,  and all  outstanding
Obligations,  including unpaid interest,  shall continue to accrue interest from
the date of such Event of  Default  at such  interest  rate  applicable  to such
Obligations  until such Event of  Default  is cured or waived.

     5.4. Cumulative Remedies. The remedies under this Note shall be cumulative.


                                   ARTICLE VI
                                 MISCELLANEOUS

     6.1.  Failure or Indulgence Not Waiver.  No failure or delay on the part of
the Holder  hereof in the exercise of any power,  right or  privilege  hereunder
shall operate as a waiver thereof,  nor shall any single or partial  exercise of
any such power, right or privilege preclude other or further exercise thereof or
of any other  right,  power or  privilege.  All  rights  and  remedies  existing
hereunder  are  cumulative  to, and not  exclusive  of,  any rights or  remedies
otherwise available.

     6.2. Notices.  Any notice herein required or permitted to be given shall be
in writing and provided in accordance with the terms of the Security  Agreement.

     6.3. Amendment  Provision.  The term "Note" and all reference  thereto,  as
used  throughout  this  instrument,  shall mean this  instrument  as  originally
executed,  or  if  later  amended  or  supplemented,   then  as  so  amended  or
supplemented, and any successor instrument as it may be amended or supplemented.

     6.4.  Assignability.  This Note shall be binding  upon the Borrower and its
successors  and  assigns,  and shall  inure to the benefit of the Holder and its
successors and assigns, and may be assigned by the Holder in accordance with the
requirements of the Security Agreement.

     6.5.  Cost of  Collection.  If default is made in the payment of this Note,
the  Borrower  shall  pay the  Holder  hereof  reasonable  costs of  collection,
including  reasonable  attorneys'  fees.

     6.6.  Governing  Law.  This Note  shall be  governed  by and  construed  in
accordance with the laws of the State of New York,  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 New York or in the federal courts located in the state of
New York.  Both  parties and the  individual  signing this Note on behalf of the
Borrower  agree to submit to the  jurisdiction  of such courts.  The  prevailing
party  shall  be  entitled  to  recover  from the  other  party  its  reasonable
attorney's  fees and  costs.  In the event  that any  provision  of this Note 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 unenforceability of any other provision of this
Note. Nothing contained herein shall be deemed or operate to preclude the Holder
from  bringing  suit or taking  other legal  action  against the Borrower in any
other  jurisdiction  to  collect on the  Borrower's  obligations  to Holder,  to
realize on any  collateral  or any other  security for such  obligations,  or to
enforce  a  judgment  or other  court  order in favor of  Holder.

     6.7.  Maximum  Payments.  Nothing  contained  herein  shall  be  deemed  to
establish  or require  the  payment of a rate of  interest  or other  charges in
excess of the maximum permitted by applicable law. In the event that the rate of
interest  required  to be paid or other  charges  hereunder  exceed the  maximum
permitted by such law, any payments in excess of such maximum  shall be credited
against  amounts  owed by the  Borrower  to the Holder and thus  refunded to the
Borrower.

     6.8. Security Interest. The Holder of this Note has been granted a security
interest in certain  assets of the Borrower  more fully  described in a Security
Agreement  dated  as  of  March  ___,  2004.

     6.9.   Construction.   Each  party  acknowledges  that  its  legal  counsel
participated in the preparation of this Note and, therefore, stipulates that the
rule of construction  that  ambiguities are to be resolved  against the drafting
party shall not be applied in the interpretation of this Note to favor any party
against the other.

     Balance of page intentionally left blank; signature page follows.



<PAGE>



     IN WITNESS  WHEREOF,  the  Borrower  has caused  this  Secured  Convertible
Revolving  Note to be signed in its name effective as of this ____ day of March,
2004.



                                        VERIDIUM CORPORATION





                                        By:__________________________________

                                             Name:
                                             Title:

WITNESS:

___________________________







<PAGE>




                              NOTICE OF CONVERSION



(To be executed by the Holder in order to convert the Note)



                  The undersigned hereby elects to convert $_________ of the
principal and $_________ of the interest due on the Secured Convertible
Revolving Note issued by VERIDIUM CORPORATION on ________ __, 2004 into Shares
of Common Stock of VERIDIUM CORPORATION (the "Borrower") according to the
conditions set forth in such Note, as of the date written below.

Date of Conversion:____________________________________________________________

Conversion Price:______________________________________________________________

Shares To Be Delivered:________________________________________________________

Signature:_____________________________________________________________________

Print Name:____________________________________________________________________

Address:_______________________________________________________________________

_______________________________________________________________________________

Holder  DWAC instructions          ___________________________________________