exhibit10_3.htm

Exhibit 10.3


     

    THIS
      WARRANT AND THE UNDERLYING SECURITIES HAVE NOT BEEN REGISTERED UNDER THE
      SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”) OR QUALIFIED UNDER ANY
      APPLICABLE SECURITIES LAWS. THEY MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED,
      HYPOTHECATED OR TRANSFERRED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION
      STATEMENT UNDER THE SECURITIES ACT AND QUALIFICATION UNDER SUCH STATE SECURITIES
      LAWS OR AN OPINION OF COUNSEL OR OTHER EVIDENCE SATISFACTORY TO THE COMPANY
      THAT
      SUCH REGISTRATION AND/OR QUALIFICATION IS NOT REQUIRED.

     

    JAYHAWK
      ENERGY, INC.

     

    WARRANT
      AGREEMENT

    


    July
      ___, 2007

    


    THIS
      CERTIFIES THAT , for value received, _______________, a _______________
      (the “ Investor ”), or Investor’s assigns (Investor and Investor’s
      assigns being the “ Holder ”), is entitled to subscribe for and purchase
      at any time during the Exercise Period from Jayhawk Energy, Inc., a Nevada
      corporation, with an office located at 370 Interlocken Blvd., Suite 400,
      Broomfield, CO 80021 (the “ Company ”), a number of shares of Common
      Stock equal to the Share Number at a per share price equal to the Exercise
      Price
      in effect at such time. This Warrant is issued in conjunction with the shares
      of
      the Company’s Common Stock issued pursuant to the Subscription Agreement dated
      as of _________ ___, 2007, by and between the Company and the
      Investor.

     

    1. Definitions.
      As used herein, the following terms shall have the following respective
      meanings:

     

    (a)
       “Aggregate Warrant Price” shall mean the dollar value obtained by
      multiplying $1.00 by ________.

     

    (b)
       “Common Stock” shall mean the common stock of the Company.

     

    (c)
       “Exercise Period” shall mean the period commencing on July ___, 2007, and
      ending on ______________ __, 2009.

     

    (d)
       “Exercise Price” shall mean $1.00 per share of Common Stock.

     

    (e)
       “Exercise Shares” shall mean any Common Stock acquired upon exercise of
      this Warrant.

     

    (f)
       “Share Number”, at any time, shall mean (i) the Aggregate Warrant Price
      minus the aggregate exercise price previously paid upon exercise of this
      Warrant, divided by (ii) the Exercise Price then in effect.

     

    
      
         

      

      
        1

        
          

        

      

      
         

      

    

     

     

    2. Exercise
      of Warrant .

     

    2.1
       General; Exercise of Warrant .

     

    (a)
       The rights represented by this Warrant may be exercised as a whole or in
      part at any time during the Exercise Period, by delivery of the following to
      the
      Company at its address set forth above (or at such other address as it may
      designate by notice in writing to the Holder):

     

    (i)           An
      executed Notice of Exercise in the form attached hereto;

     

    (ii)           Payment
      of the Exercise Price either in cash or by check; and

     

    (iii)           This
      Warrant.

     

    (b)
       Upon the exercise of the rights represented by this Warrant, a certificate
      or certificates for the Exercise Shares so purchased, registered in the name
      of
      the Holder or persons affiliated with the Holder, if the Holder so designates
      (and such designation is in compliance with applicable securities laws and
      any
      stockholders, investor rights or similar agreement), shall be issued and
      delivered to the Holder as promptly as practicable after the rights represented
      by this Warrant shall have been so exercised.

     

    (c)
       The person in whose name any certificate or certificates for Exercise
      Shares are to be issued upon exercise of this Warrant shall be deemed to have
      become the holder of record of such shares on the date on which this Warrant
      was
      surrendered and payment of the Exercise Price was made, irrespective of the
      date
      of delivery of such certificate or certificates, except that, if the date of
      such surrender and payment is a date when the stock transfer books of the
      Company are closed, such person shall be deemed to have become the holder of
      such shares at the close of business on the next succeeding date on which the
      stock transfer books are open.

     

    2.2
       Net Issue Exercise .

     

    (a)
       In lieu of paying the Exercise Price in cash or by check as provided in
      Section 2.1, the Holder may elect a “Net Issue Exercise” pursuant to which the
      Holder will receive Exercise Shares equal to the value (as determined below)
      of
      this Warrant (or the portion thereof being exercised) by surrender of this
      Warrant at the principal office of the Company together with an executed Notice
      of Exercise in the form attached hereto in which event the Company shall issue
      to the Holder a number of Exercise Shares computed using the following
      formula:

     

    X
      = Y
      (A-B)

    A

    Where:

     

    X
      = the
      number of Exercise Shares to be issued to the Holder;

     

    
      
         

      

      
        2

        
          

        

      

      
         

      

    

     

     

    Y
      = the
      number of Exercise Shares purchasable under the Warrant or, if only a portion
      of
      the Warrant is being exercised, the portion of the Warrant being exercised
      (at
      the date of such exercise);

     

    A
      = the
      Fair Market Value of one share of the Company’s Common Stock (at the date of
      such exercise); and

     

    B
      = the
      Exercise Price (as adjusted to the date of such exercise).

     

    (b)
       For purposes of the above calculation, “Fair Market Value” shall be
      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 Stock Market’s
      Global Select or Global Market, the Fair Market Value of a share of Common
      Stock
      will be the average closing sales price for such stock (or the closing bid,
      if
      no sales are reported) as quoted on that system or exchange (or the system
      or
      exchange with the greatest volume of trading in Common Stock), over the five
      (5)
      trading day period ending on the trading day immediately preceding the day
      the
      Warrant is being exercised, as reported in the Wall Street Journal or any other
      source the Company considers reliable.

     

    (ii)
       If the Common Stock is quoted on The Nasdaq Stock Market ( but not on The
      Nasdaq Stock Market’s Global Select or Global Market) or is regularly quoted
      elsewhere by recognized securities dealers but selling prices are not reported,
      the Fair Market Value of a share of Common Stock will be the average mean
      between the high bid and low asked prices for the Common Stock over the five
      (5)
      trading day period ending on the trading day immediately preceding the day
      the
      Warrant is being exercised, as reported in the Wall Street Journal or any other
      source the Company considers reliable.

     

    (iii)
       If the Common Stock is not traded as set forth above, the Fair Market
      Value will be determined in good faith by the Board of Directors of the
      Company.

     

    (c)
       If this Warrant is not exercised in full by a Net Issue Exercise, then,
      the “Share Number” in effect immediately after such partial exercise shall be
      appropriately adjusted to take into account the effect of the Net Issue
      Exercise.

     

    3. Covenants
      of the Company.

     

    3.1
       Covenants as to Exercise Shares . The Company covenants and agrees
      that all Exercise Shares that may be issued upon the exercise of the rights
      represented by this Warrant will, upon issuance, be validly issued and
      outstanding, fully paid and nonassessable, and free from all taxes, liens and
      charges with respect to the issuance thereof. The Company further covenants
      and
      agrees that the Company will at all times during the Exercise Period have
      authorized and reserved, free from preemptive rights, a sufficient number of
      shares of its Common Stock to provide for the exercise of the rights represented
      by this Warrant. If at any time during the Exercise Period the number of
      authorized but unissued shares of Common Stock shall not be sufficient to permit
      exercise of this Warrant, the Company will take such corporate action as may,
      in
      the opinion of its counsel, be necessary to increase its authorized but unissued
      shares of Common Stock to such number of shares as shall be sufficient for
      such
      purposes.

     

    
      
         

      

      
        3

        
          

        

      

      
         

      

    

     

     

    3.2
       No Impairment . Except and to the extent as waived or consented to
      by the Holder, the Company will not, by amendment of its Articles of
      Incorporation or through any reorganization, transfer of assets, consolidation,
      merger, dissolution, issue or sale of securities, or any other voluntary action,
      avoid or seek to avoid the observance or performance of any of the terms to
      be
      observed or performed hereunder by the Company, but will at all times in good
      faith assist in the carrying out of all the provisions of this Warrant and
      in
      the taking of all such action as may be necessary or appropriate in order to
      protect the exercise rights of the Holder against impairment.

     

    3.3
       Notices of Record Date . In the event of any taking by the Company
      of a record of the holders of any class of securities for the purpose of
      determining the holders thereof who are entitled to receive any dividend (other
      than a cash dividend which is the same as cash dividends paid in previous
      quarters) or other distribution, the Company shall mail to the Holder, at least
      ten (10) days prior to the date specified herein, a notice specifying the date
      on which any such record is to be taken for the purpose of such dividend or
      distribution.

     

    4. Representations
      of Holder.

     

    4.1
       Acquisition of Warrant for Personal Account . The Holder represents
      and warrants that it is acquiring the Warrant and any shares of capital stock
      issued or issuable upon exercise or conversion of the Warrant for investment
      purposes only and not with a view to or for resale in connection with any
      distribution or public offering thereof within the meaning of the Act (as
      defined below). The Holder also represents that the entire legal and beneficial
      interests of the Warrant and Exercise Shares the Holder is acquiring is being
      acquired for, and will be held for, the account of the Holder only.

     

    4.2
       Accredited Investor; Off-Shore Transaction; Not a U.S. Person . The
      Holder represents and warrants that, unless not a “U.S. Person” as defined
      below, the Holder it is an “accredited investor” as such term is defined in Rule
      501 under the Securities Act of 1933, as amended (the “ Act ”). The
      Holder shall provide the Company with such additional information as the Company
      may reasonably request with respect to the Holder’s status as an “accredited
      investor.” The exercise of this Warrant and the transactions contemplated herein
      may constitute an “off-shore transaction,” as that term is defined in Rule
      902(h) of Regulations S promulgated under the Securities Act. If the Holder
      is
      not an accredited investor, then the Holder is not a “U.S. Person,” as that term
      is defined in Rule 902(k) of Regulation S promulgated under the Securities
      Act.

     

    4.3
       Securities Are Not Registered .

     

    (a)
       The Holder understands that the Warrant and the Exercise Shares have not
      been registered under the Act, on the basis that no distribution or public
      offering of the stock of the Company is to be effected, or registered or
      qualified under any applicable state securities laws. The Holder realizes that
      the basis for the exemption may not be present if, notwithstanding its
      representations, the Holder has a present intention of acquiring the securities
      for a fixed or determinable period and, in the future, selling (in connection
      with a distribution or otherwise), granting any participation in, or otherwise
      distributing the securities. The Holder has no such present
      intention.

     

    
      
         

      

      
        4

        
          

        

      

      
         

      

    

     

     

    (b)
       The Holder recognizes that the Warrant and the Exercise Shares must be
      held indefinitely unless they are subsequently registered under the Act or
      an
      exemption from such registration is available. The Company has no obligation
      to
      register the Warrant or the Exercise Shares of the Company, or to comply with
      any exemption from such registration.

     

    (c)
       The Holder is aware that neither the Warrant nor the Exercise Shares may
      be sold pursuant to Rule 144 adopted under the Act unless certain conditions
      are
      met, including, among other things, the existence of a public market for the
      shares, the availability of certain current public information about the
      Company, the resale following the required holding period under Rule 144 and
      the
      number of shares being sold during any three (3) month period not exceeding
      specified limitations. For so long as the Warrants are outstanding and for
      the
      two-year period thereafter, the Company will use its best efforts to satisfy
      these conditions.

     

    (d)
       The Holder is aware of the Company’s business affairs and financial
      condition and has acquired sufficient information about the Company to reach
      an
      informed and knowledgeable decision regarding its investment in the Company.
      The
      Holder is experienced in making investments of this type and has such knowledge
      and background in financial and business matters that the Holder is capable
      of
      evaluating the merits and risks of this investment and protecting its own
      interests. The Holder has had an opportunity to ask questions of, and receive
      answers from, the Company and its officers and employees regarding the business,
      financial affairs and other aspects of the Company, and has further had the
      opportunity to obtain information (to the extent the Company possesses or can
      acquire such information without unreasonable effort or expense) which the
      Holder deems necessary to evaluate an investment in the Company and to verify
      the accuracy of information otherwise provided to the Holder.

     

    4.4
       Disposition of Warrant and Exercise Shares .

     

    (a)
       Except for transfers by the Holder to its affiliates in compliance with
      all applicable securities laws, the Holder further agrees not to make any
      disposition of all or any part of the Warrant or Exercise Shares in any event
      unless and until:

     

    (i)
       The Company shall have received a letter secured by the Holder from the
      Securities and Exchange Commission stating that no action will be recommended
      to
      the Commission with respect to the proposed disposition; or

     

    (ii)
       There is then in effect a registration statement under the Act covering
      such proposed disposition and such disposition is made in accordance with said
      registration statement; or

     

    
      
         

      

      
        5

        
          

        

      

      
         

      

    

     

     

    (iii)
       The Holder shall have shall have furnished the Company with an opinion of
      counsel, reasonably satisfactory to the Company, for the Holder to the effect
      that such disposition will not require registration of such Warrant or Exercise
      Shares under the Act or any applicable state securities laws.

     

    (b)
       The Holder understands and agrees that all certificates evidencing the
      Exercise Shares to be issued to the Holder may bear the following legend (in
      addition to any legend required under applicable state securities laws, the
      Company’s Bylaws, or as provided elsewhere in this Warrant):

     

    THESE
      SECURITIES HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED
      (THE “SECURITIES ACT”) OR QUALIFIED UNDER ANY APPLICABLE SECURITIES LAWS. THEY
      MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED, HYPOTHECATED OR TRANSFERRED IN
      THE
      ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT AND
      QUALIFICATION UNDER SUCH STATE SECURITIES LAWS OR AN OPINION OF COUNSEL OR
      OTHER
      EVIDENCE SATISFACTORY TO THE COMPANY THAT SUCH REGISTRATION AND/OR QUALIFICATION
      IS NOT REQUIRED.

     

    5. Adjustments
      and Notices. The Exercise Price and the number of
      Exercise Shares issuable upon exercise of this Warrant shall be subject to
      adjustment from time to time in accordance with this Section 5.

     

    5.1
       Subdivision, Stock Dividends or Combinations . In case the Company
      shall at any time after the commencement of the Exercise Period subdivide the
      outstanding Common Stock or shall issue a stock dividend with respect to the
      Common Stock, the Exercise Price in effect immediately prior to such subdivision
      or the issuance of such dividend shall be proportionately decreased, and in
      case
      the Company shall at any time after the commencement of the Exercise Period
      combine the outstanding shares of Common Stock, the Exercise Price in effect
      immediately prior to such combination shall be proportionately increased, in
      each case effective at the close of business on the date of such subdivision,
      dividend, or combination, as the case may be.

     

    5.2
       Reclassification, Exchange, Substitution, In-Kind Distribution .
      Upon any reclassification, exchange, substitution or other event after the
      commencement of the Exercise Period that results in a change of the number
      and/or class of the securities issuable upon exercise or conversion of this
      Warrant or upon the payment after the commencement of the Exercise Period of
      a
      dividend in securities or property other than shares of Common Stock, the Holder
      shall be entitled to receive, upon exercise or conversion of this Warrant,
      the
      number and kind of securities and property that Holder would have received
      if
      this Warrant had been exercised or converted immediately before the record
      date
      for such reclassification, exchange, substitution, or other event or immediately
      prior to the record date for such dividend. The Company or its successor shall
      promptly issue to Holder a new warrant for such new securities or other
      property. The new warrant shall provide for adjustments, which shall be as
      nearly equivalent as may be practicable to the adjustments provided for in
      this
      Section 5, including, without limitation, adjustments to the Warrant Price
      and
      to the number of securities or property issuable upon exercise or conversion
      of
      the new warrant. The provisions of this Section 5.2 shall similarly apply to
      successive reclassifications, exchanges, substitutions, or other events and
      successive dividends.

     

    
      
         

      

      
        6

        
          

        

      

      
         

      

    

     

     

    5.3
       Consolidation, Merger, Sale and the Like . In case of any (i)
      merger or consolidation of the Company into or with another corporation where
      the Company is not the surviving corporation (but including a merger for the
      purpose of reincorporating in a new domicile) (ii) sale, transfer or lease
      (but
      not including a transfer or lease by pledge or mortgage to a bona fide lender)
      of all or substantially all of the assets of the Company or (iii) sale by
      the Company’s stockholders of 50% or more of the Company’s outstanding
      securities in one or more related transactions, the Company, or such successor
      or purchasing corporation, as the case may be, shall duly execute and deliver
      to
      the Holder hereof a new warrant so that the Holder shall have the right to
      receive upon exercise or conversion of the unexercised or unconverted portion
      of
      this Warrant, at a total purchase price not to exceed that payable upon the
      exercise or conversion of the unexercised or unconverted portion of this
      Warrant, and in lieu of shares of Common Stock theretofore issuable upon
      exercise or conversion of this Warrant, the kind and amount of shares of stock,
      or other securities, money and other property in lieu of such shares of stock,
      receivable upon or as a result of such reorganization, merger, or sale by a
      holder of the number of shares of Common Stock for which this Warrant is
      exercisable or convertible immediately prior to such event. Such new warrant
      shall provide for adjustments that shall be as nearly equivalent as may be
      practicable to the adjustments provided for in this Section 5. The provisions
      of
      this Section 5.3 shall similarly apply to successive reorganizations,
      mergers, and sales.

     

    5.4
       In each case of an adjustment or readjustment of the Exercise Price
      pursuant to this Section 5, the Company, at its expense, shall compute such
      adjustment or readjustment in accordance with the provisions hereof and prepare
      a certificate showing such adjustment or readjustment, and shall mail such
      certificate, by first class mail, postage prepaid, to the Holder at the Holder’s
      address as shown in the Company’s books. The certificate shall set forth such
      adjustment or readjustment, showing in reasonable detail the facts upon which
      such adjustment or readjustment is based, including a statement of, if
      applicable, the type and amount, if any, of other property which at the time
      would be received upon exercise of this Warrant.

     

    6. Fractional
      Shares. No fractional shares shall be issued upon
      the exercise of this Warrant as a consequence of any adjustment pursuant hereto.
      All Exercise Shares (including fractions) issuable upon exercise of this Warrant
      may be aggregated for purposes of determining whether the exercise would result
      in the issuance of any fractional share. No payments shall be made by the
      Company in respect of any fractional shares otherwise issuable pursuant to
      this
      Warrant.

     

    7. No
      Stockholder Rights. This Warrant in and of itself
      shall not entitle the Holder to any voting rights or other rights as a
      stockholder of the Company.

     

    8. Transfer
      of Warrant. Subject
      to applicable laws, the restriction on transfer set forth on the first page
      of
      this Warrant and in Section 4.4 and the terms of any applicable stockholders,
      investor rights, or similar agreements, this Warrant and all rights hereunder
      are transferable, by the Holder in person or by duly authorized attorney, upon
      delivery of this Warrant and the form of assignment attached hereto to any
      transferee designated by Holder, provided that the transferee shall have signed
      an investment letter in form and substance satisfactory to the Company and
      agreed to be bound by the provisions of this Warrant. Notwithstanding anything
      to the contrary, no partial transfer of this Warrant shall be
      permitted.

     

    
      
         

      

      
        7

        
          

        

      

      
         

      

    

     

     

    9. Lost,
      Stolen, Mutilated or Destroyed
      Warrant. If this Warrant is lost, stolen,
      mutilated, or destroyed, the Company may, on such terms as to indemnity or
      otherwise as it may reasonably impose (which shall, in the case of a mutilated
      Warrant, include the surrender thereof), issue a new Warrant of like
      denomination and tenor as the Warrant so lost, stolen, mutilated, or destroyed.
      Any such new Warrant shall constitute an original contractual obligation of
      the
      Company, whether or not the allegedly lost, stolen, mutilated, or destroyed
      Warrant shall be at any time enforceable by anyone.

    


    10.
       Notices, Etc.
All notices and
      other communications required or permitted hereunder
      shall be in writing and shall be sent by express mail or other form of rapid
      communications, if possible, and if not then such notice or communication shall
      be mailed by first-class mail, postage prepaid, addressed in each case to the
      party entitled thereto at the following addresses: (a) if to the Company, to
      Jayhawk Energy, Attention: President, 370 Interlocken Blvd., Suite 400,
      Broomfield, CO 80021 , and (b) if to the Holder, to such address as originally
      furnished to the Company by the Holder, or at such other address as one party
      may furnish to the other in writing. Notice shall be deemed effective on the
      date dispatched if by personal delivery, two days after mailing if by express
      mail, or three days after mailing if by first-class mail.

     

    11.
       Amendment. This
      Warrant may be amended or otherwise modified only by a writing signed by the
      Company and the Holder.

     

    12. Acceptance.
      Receipt of this Warrant by the Holder shall constitute acceptance of and
      agreement to all of the terms and conditions contained herein.

     

    13.
       Governing Law;
      Forum. This Warrant and all rights, obligations,
      and liabilities hereunder shall be governed by the internal laws of the State
      of
      Colorado and any actions related hereto shall be brought in a court of competent
      jurisdiction located in the County of Broomfield, State of
      Colorado.

     

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    IN
      WITNESS WHEREOF, the Company has caused this Warrant to be executed by its
      duly
      authorized officer as of the date first written above.

     

     

    
      	
               

            	
              JAYHAWK
                ENERGY, INC.

            
	
               

            	
              a
                Colorado corporation

            
	
               

            	
               

            
	
               

            	
               

            
	
               

            	
              By:_________________________________________

            
	
               

            	
              Name:
                Lindsay Gorrill

            
	
               

            	
              Title:
                President 

            


    

     


    
      
         

      

      
        9

        
          

        

      

      
         

      

    


    NOTICE
      OF EXERCISE

     

    To:           Jayhawk
      Energy, Inc.

     

    1.
       The undersigned hereby elects to purchase ________ shares of the Common
      Stock of Jayhawk Energy, Inc. (the “Company”) pursuant to the terms of
      the attached Warrant, and tenders herewith payment of the exercise price in
      full
      pursuant to the terms of Section 2.1 of the attached Warrant, or by net issue
      exercise pursuant to the terms of Section 2.2 of the attached Warrant, together
      with all applicable transfer taxes, if any.

     

    2.
       Please issue a certificate or certificates representing said shares of
      Common Stock in the name of the undersigned or in such other name as is
      specified below:

     

    
      	
               

            	
              ________________________

            
	
               

            	
              (Name)

            
	
               

            	
               

            
	
               

            	
              ________________________

            
	
               

            	
              ________________________

            
	
               

            	
              (Address)

            


    

     

    3.
       The undersigned represents that (i) the aforesaid shares of Common Stock
      are being acquired for the account of the undersigned for investment purposes
      only and not with a view to, or for resale in connection with, the distribution
      thereof and that the undersigned has no present intention of distributing or
      reselling such shares; (ii) the undersigned is aware of the Company’s
      business affairs and financial condition and has acquired sufficient information
      about the Company to reach an informed and knowledgeable decision regarding
      its
      investment in the Company; (iii) the undersigned is experienced in making
      investments of this type and has such knowledge and background in financial
      and
      business matters that the undersigned is capable of evaluating the merits and
      risks of this investment and protecting the undersigned’s own interests; (iv)
      the undersigned is an “accredited investor” as defined in Rule 501 under the
      Securities Act of 1933, as amended (the “ Securities Act ”); (v) the
      undersigned understands that the shares of Common Stock issuable upon exercise
      of this Warrant have not been registered under the Securities Act by reason
      of a
      specific exemption from the registration provisions of the Securities Act,
      which
      exemption depends upon, among other things, the bona fide nature of the
      investment intent as expressed herein, and, because such securities have not
      been registered under the Securities Act, they must be held indefinitely unless
      subsequently registered under the Securities Act or an exemption from such
      registration is available; (vi) the undersigned is aware that the aforesaid
      shares of Common Stock may not be sold pursuant to Rule 144 adopted under the
      Securities Act unless certain conditions are met and until the undersigned
      has
      held the shares for the number of years prescribed by Rule 144; and (vii) the
      undersigned agrees not to make any disposition of all or any part of the
      aforesaid shares of Common Stock unless and until there is then in effect a
      registration statement under the Securities Act covering such proposed
      disposition and such disposition is made in accordance with said registration
      statement, or the undersigned has provided the Company with an opinion of
      counsel satisfactory to the Company, stating that such registration is not
      required.

     

    
      	
              ________________________

            	
              ________________________

            
	
              (Date)

            	
              (Signature)

            
	
               

            	
               

            
	
               

            	
              ________________________

            
	
               

            	
              (Print
                name)

            


    

     

     

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