Exhibit
10.102


 


This
warrant and the securities issuable upon the exercise hereof have not been registered under the Securities Act of 1933, as amended.
They may not be sold, offered for sale, pledged, hypothecated, or otherwise transferred except PURSUANT to an effective registration
statement under the Securities Act of 1933, as amended, or an opinion of counsel satisfactory to the Company the registration
is not required.


 


	No.
    of Shares: 	107,000	Issue
    Date:	December
    23, 2019
	Exercise
    Price: 	$1.40	Expiration
    Date:	December
    23, 2024


 


DIGITAL
ALLY, INC.


 


Common
Stock Purchase Warrant


 


DIGITAL
ALLY, INC. (the “Company”), a Nevada corporation, hereby certifies that, for value received of $0.001 per
Warrant, Michael Doherty, a Kansas Resident, whose address is 2612 W. 140th Street, Leawood, KS 66224
or its assignees (the “Holder”), is entitled, subject to the terms set forth below, at any time, or from time to time,
after the date hereof and before the Expiration Date (as defined below), to purchase from the Company one hundred seven thousand
(107,000) shares (the “Shares”) of common stock, $0.001 par value (the “Common Stock”),
of the Company at a price of One and Forty One Hundredths Dollars ($1.40) per Share. The purchase price per Share, as adjusted
from time to time pursuant to the provisions of this Warrant, is referred to as the “Exercise Price.”


 


1.
Term of the Warrant.


 


1.1
Time of Exercise. Subject to the provisions of Sections 1.5, “Transfer and Assignment,” and 3.1,
“Registration and Legends,” this Warrant may be exercised at any time and from time to time after 9:00 a.m., local
time, on December 23, 2019 (the “Exercise Commencement Date”), but no later than 5:00 p.m., local time,
December 23, 2024 (the “Expiration Date”), at which point it shall become void and all rights under
this Warrant shall cease.


 


1.2
Manner of Exercise. Subject to the provisions of Section 1.4, “Holder as Owner,” the Holder may
exercise this Warrant in whole or in part on the date hereof or by presentation and surrender thereof to the Company at its principal
executive office or at the office of its stock transfer agent, if any, the subscription form annexed hereto (the “Subscription
Form”) duly executed and accompanied by payment as follows:


 


1.2.1
in cash or by certified or official bank check, payable to the order of the Company, in the amount equal to the Exercise Price
multiplied by the number of Shares specified in such form, together with all taxes applicable upon such exercise;


 


1.2.2
by surrendering to the Company that number of Shares owned by the Holder whose value is equal to the Exercise Price multiplied
by the number of Shares specified in the Subscription Form;


 




    	 



    	 



    

 


1.2.3
by surrendering the right to acquire a number of Shares having an aggregate value such that the amount by which the aggregate
value of such Shares exceeds the aggregate Exercise Price is equal to the Exercise Price;


 


1.2.4
any combination of the foregoing; or


 


1.2.5
any other manner acceptable to the Company.


 


For
purposes of surrendering Shares to satisfy the Exercise Price, the value of the Shares shall be equal to the current market price
for Common Stock (the “Market Price”) on the relevant date of such exercise of this Warrant from time to time
(the “Exercise Date”).


 


	 	 	Y
    (A - B)	 
	 	X
    =	A	 


 


Where


 


X
— The number of Shares to be issued to the Holder.


 


Y
— The number of Shares purchasable under this Warrant.


 


A
— The Market Price of one Share.


 


B
— The Exercise Price (as adjusted to the date of such calculations).


 


For
purposes of this Section 1, the Market Price of a Share shall mean the average of the closing bid and asked prices of Shares quoted
on the Nasdaq Capital Market or in the over-the-counter market in which the Shares are traded or the closing sale price quoted
on any exchange on which the Shares are listed, whichever is applicable, for the ten (10) trading days prior to the date of determination
of Market Price (or such shorter period of time during which such stock was traded over-the-counter or on such exchange). If the
Shares are not traded on the over-the-counter market or on an exchange, the Market Price shall be the price per Share at which
the Company sold Common Stock previous to the date of exercise.


 


1.2.6
Upon receipt of this Warrant, with the Subscription Form duly executed and accompanied by payment of the aggregate Exercise Price
for the Shares for which this Warrant is then being exercised, the Company shall cause to be issued certificates or other evidence
of ownership for the total number of whole Shares for which this Warrant is being exercised in such denominations as are required
for delivery to the Holder, and the Company shall thereupon deliver such documents to the Holder or its nominee.


 


1.2.7
If the Holder exercises this Warrant with respect to fewer than all the Shares that may be purchased under this Warrant, the Company
shall execute a new Warrant for the balance of the Shares that may be purchased upon exercise of this Warrant and deliver such
new Warrant to the Holder.


 


1.2.8
The Company covenants and agrees that it will pay when due and payable all transfer taxes which may be payable in respect of the
issue of this Warrant, or the issue of any Shares upon the exercise of this Warrant. The Company shall not, however, be required
to pay any transfer or other tax which may be payable in respect of any transfer involved in the issuance or delivery of this
Warrant or of the Shares in a name other than that of the Holder at the time of surrender, and until the payment of such tax,
the Company shall not be required to issue such Shares.


 




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1.2.9
The Company shall, at the time of any exercise of all or part of this Warrant, upon the request of the Holder hereof, acknowledge
in writing its continuing obligation to afford to such Holder any rights to which such Holders shall continue to be entitled after
such exercise in accordance with the provisions of this Warrant, provided that if the Holder of this Warrant shall fail to make
any such request, such failure shall not affect the continuing obligations of the Company to afford to such Holder any such rights.


 


1.3
Exchange of Warrant. This Warrant may be split-up, combined or exchanged for another Warrant or Warrants
of like tenor to purchase a like aggregate number of Shares. If the Holder desires to split-up, combine or exchange this Warrant,
he shall make such request in writing delivered to the Company at its corporate office and shall surrender this Warrant and any
other Warrants to be so split-up, combined or exchanged, the Company shall execute and deliver to the person entitled thereto
a Warrant or Warrants, as the case may be, as so requested. The Company shall not be required to effect any split-up, combination
or exchange that will result in the issuance of a Warrant entitling the Holder to purchase upon exercise a fraction of a Share.
The Company may require the Holder to pay a sum sufficient to cover any tax or governmental charge that may be imposed in connection
with any split-up, combination or exchange of Warrants. The term “Warrant” as used herein includes any Warrants issued
in substitution for or replacement of this Warrant, or into which this Warrant may be divided or exchanged.


 


1.4
Holder as Owner. Prior to due presentment for registration of transfer of this Warrant, the Company may deem
and treat the Holder as the absolute owner of this Warrant (notwithstanding any notation of ownership or other writing hereon)
for the purpose of any exercise hereof and for all other purposes, and the Company shall not be affected by any notice to the
contrary. Irrespective of the date of issue and delivery of certificates for any Shares issuable upon the exercise of the Warrant,
each person in whose name any such certificate is issued shall be deemed to have become the holder of record of the Shares represented
thereby on the date on which all or a portion of the Warrant surrendered in connection with the subscription therefor was surrendered
and payment of the Exercise Price was tendered. No surrender of all or a portion of the Warrant on any date when the stock transfer
books of the Company are closed, however, shall be effective to constitute the person or persons entitled to receive Shares upon
such surrender as the record holder of such Shares on such date, but such person or persons shall be constituted the record holder
or holders of such Shares at the close of business on the next succeeding date on which the stock transfer books are opened. Each
person holding any Shares received upon exercise of Warrant shall be entitled to receive only dividends or distributions payable
to holders of record on or after the date on which such person shall be deemed to have become the holder of record of such Shares.


 


1.5
Transfer and Assignment. This Warrant may not be sold, hypothecated, exercised, assigned or transferred except
in accordance with and subject to the provisions of the Securities Act of 1933, as amended (“Act”).


 




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1.6
Method for Assignment. Any assignment permitted under this Warrant shall be made by surrender of this Warrant
to the Company at its principal office with the form of assignment attached hereto duly executed and funds sufficient to pay any
transfer tax. In such event, the Company shall, without charge, execute and deliver a new Warrant in the name of the assignee
designated in such instrument of assignment and this Warrant shall promptly be canceled. This Warrant may be divided or combined
with other Warrants that carry the same rights upon presentation thereof at the corporate office of the Company together with
a written notice signed by the Holder, specifying the names and denominations in which such new Warrants are to be issued.


 


1.7
Rights of Holder. Nothing contained in this Warrant shall be construed as conferring upon the Holder the
right to vote or consent or receive notice as a stockholder in respect of any meetings of stockholders for the election of directors
or any other matter, or as having any rights whatsoever as a stockholder of the Company. If, however, at any time prior to the
expiration of this Warrant and prior to its exercise, any of the following shall occur:


 


1.7.1
The Company shall take a record of the holders of its shares of Common Stock for the purpose of entitling them to receive a dividend
or distribution payable otherwise than in cash, or a cash dividend or distribution payable otherwise than out of current or retained
earnings, as indicated by the accounting treatment of such dividend or distribution on the books of the Company; or


 


1.7.2
The Company shall offer to the holders of its Common Stock any additional shares of capital stock of the Company or securities
convertible into or exchangeable for shares of capital stock of the Company, or any option, right or warrant to subscribe therefor;
or


 


1.7.3
There shall be proposed any capital reorganization or reclassification of the Common Stock, or a sale of all or substantially
all of the assets of the Company, or a consolidation or merger of the Company with another entity; or


 


1.7.4
There shall be proposed a voluntary or involuntary dissolution, liquidation or winding up of the Company;


 


then,
in any one or more of said cases, the Company shall cause to be mailed to the Holder, at the earliest practicable time (and, in
any event, not less than thirty (30) days before any record date or other date set for definitive action), written notice of the
date on which the books of the Company shall close or a record shall be taken to determine the stockholders entitled to such dividend,
distribution, convertible or exchangeable securities or subscription rights, or entitled to vote on such reorganization, reclassification,
sale, consolidation, merger, dissolution, liquidation or winding up, as the case may be. Such notice shall also set forth such
facts as shall indicate the effect of such action (to the extent such effect may be known at the date of such notice) on the Exercise
Price and the kind and amount of the Common Stock and other securities and property deliverable upon exercise of this Warrant.
Such notice shall also specify the date as of which the holders of the Common Stock of record shall participate in said distribution
or subscription rights or shall be entitled to exchange their Common Stock for securities or other property deliverable upon such
reorganization, reclassification, sale, consolidation, merger, dissolution, liquidation or winding up, as the case may be (on
which date, in the event of voluntary or involuntary dissolution, liquidation or winding up of the Company, the right to exercise
this Warrant shall terminate). Without limiting the obligation of the Company to provide notice to the holder of actions hereunder,
the failure of the Company to give notice shall not invalidate such action of the Company.


 




    	-4-



    	 



    

 


1.8
Lost Warrant Certificate(s). Upon receipt by the Company of evidence satisfactory to it of the loss, theft,
destruction or mutilation of this Warrant, and, in the case of loss, theft or destruction of reasonably satisfactory indemnification,
including a surety bond if required by the Company, and upon surrender and cancellation of this Warrant, if mutilated, the Company
will cause to be executed and delivered a new Warrant of like tenor and date. Any such new Warrant executed and delivered shall
constitute an additional contractual obligation on the part of the Company, whether or not this Warrant so lost, stolen, destroyed,
or mutilated shall be at any time enforceable by anyone.


 


1.9
Covenants of the Company. The Company covenants and agrees as follows:


 


1.9.1
At all times it shall reserve and keep available for the exercise of this Warrant into Common Stock such number of authorized
shares of Common Stock as are sufficient to permit the exercise in full of this Warrant into Common Stock; and


 


1.9.2
All Shares issued upon exercise of the Warrant shall be duly authorized, validly issued and outstanding, fully-paid and non-assessable.


 


2.
Adjustment of Number of Shares Purchasable
Upon Exercise.


 


2.1
Recapitalization. The number of Shares purchasable on exercise of this Warrant and the Exercise Price therefor
shall be subject to adjustment from time to time in the event that the Company shall: (i) pay a dividend in, or make a distribution
of, shares of Common Stock, (ii) subdivide its outstanding shares of Common Stock into a greater number of shares, (iii) combine
its outstanding shares of Common Stock into a smaller number of shares, or (iv) spin-off a subsidiary by distributing, as a dividend
or otherwise, shares of the subsidiary to its stockholders. In any such case, the total number of shares purchasable on exercise
of this Warrant immediately prior thereto shall be adjusted so that the Holder shall be entitled to receive, at the same aggregate
purchase price, the number of shares of Common Stock that the Holder would have owned or would have been entitled to receive immediately
following the occurrence of any of the events described above had this Warrant been exercised in full immediately prior to the
occurrence (or applicable record date) of such event. An adjustment made pursuant to this Section 2 shall, in the case of a stock
dividend or distribution, be made as of the record date and, in the case of a subdivision or combination, be made as of the effective
date thereof. If, as a result of any adjustment pursuant to this Section 2, the Holder shall become entitled to receive shares
of two or more classes of series of securities of the Company, the Board of Directors of the Company shall equitably determine
the allocation of the adjusted purchase price between or among shares or other units of such classes or series and shall notify
the Holder of such allocation.


 


2.2
Merger or Consolidation. In the event of any reorganization or recapitalization of the Company or in the
event the Company consolidates with or merges into another entity or transfers all or substantially all of its assets to another
entity, then and in each such event, the Holder, on exercise of this Warrant as provided herein, at any time after the consummation
of such reorganization, recapitalization, consolidation, merger or transfer, shall be entitled, and the documents executed to
effectuate such event shall so provide, to receive the stock or other securities or property to which the Holder would have been
entitled upon such consummation if the Holder had exercised this Warrant immediately prior thereto. In such case, the terms of
this Warrant shall survive the consummation of any such reorganization, recapitalization, consolidation, merger or transfer and
shall be applicable to the shares of stock or other securities or property receivable on the exercise of this Warrant after such
consummation and as an exchange for a larger or smaller number of shares, as the case may be.


 




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2.3
Notice of Dissolution or Liquidation. Except as otherwise provided in Section 2.2, “Merger or Consolidation,”
in the case of any sale or conveyance of all or substantially all of the assets of the Company in connection with a plan of complete
liquidation of the Company, or in the case of the dissolution, liquidation or winding-up of the Company, all rights under this
Warrant shall terminate on a date fixed by the Company, such date so fixed to be not earlier than the date of the commencement
of the proceedings for such dissolution, liquidation or winding-up and not later than thirty (30) days after such commencement
date. Notice of such termination of purchase rights shall be given to the Holder at least thirty (30) days prior to such termination
date.


 


2.4
Statement of Adjustment. Any adjustment pursuant to the provisions of this Section 2 shall be made on the
basis of the number of Shares which the Holder would have been entitled to acquire by exercise of this Warrant immediately prior
to the event giving rise to such adjustment and, as to the Exercise Price in effect immediately prior to the rise to such adjustment.
Whenever any such adjustment is required to be made, the Company shall forthwith determine the new number of Shares that the Holder
hereof shall be entitled to purchase hereunder and/or such new Exercise Price and shall prepare, retain on file and transmit to
the Holder within ten (10) days after such preparation a statement describing in reasonable detail the method used in calculating
such adjustment.


 


2.5
No Fractional Shares. The Company shall not issue any fraction of a Share in connection with the exercise
of this Warrant, and in any case where the Holder would, except for the provisions of this Section 2.5, be entitled under the
terms of this Warrant to receive a fraction of a Share upon such exercise, the Company shall upon the exercise and receipt of
the Exercise Price, issue the largest number of whole Shares purchasable upon exercise of this Warrant. The Company shall not
be required to make any cash or other adjustment in respect of such fraction of a Share to which the Holder would otherwise be
entitled. The Holder, by the acceptance of this Warrant, expressly waives his right to receive a certificate for any fraction
of a Share upon exercise hereof.


 


2.6
No Change in Form Required. The form of Warrant need not be changed because of any change pursuant to this
Section 2 in the Exercise Price or in the number of Shares purchasable upon the exercise of a Warrant, may state the same Exercise
Price and the same number of shares of Common Stock as are stated in the Warrants initially issued pursuant to the Agreement.


 




    	-6-



    	 



    

 


3.
Registration Under the Securities Act of 1933.


 


3.1
Registration and Legends. The Holder understands that (i) the Company has not registered the Warrant or the
Shares under the Act, or the applicable securities laws of any state in reliance on exemptions from registration and (ii) such
exemptions depend upon the Holder’s investment intent at the time the Holder acquires the Warrant or the Shares. The Holder
therefore represents and warrants that it is acquiring the Warrant, and will acquire the Shares, for the Holder’s own account
for investment and not with a view to distribution, assignment, resale or other transfer of the Warrant or the Shares. Because
the Warrant and the Shares are not registered, the Holder is aware that the Holder must hold them indefinitely unless they are
registered under the Act and any applicable securities laws or the Holder must obtain exemptions from such registration. Upon
exercise, in part or in whole, of this Warrant, the Shares shall bear the following legend:


 


The
shares of Common Stock represented by this certificate have not been registered under the Securities Act of 1933, as amended (“Act”)
or any applicable state securities laws, and they may not be offered for sale, sold, transferred, pledged or hypothecated without
an effective registration statement under the Securities Act and under any applicable state securities laws, or an opinion of
counsel, satisfactory to the Company, that an exemption from such registration is available.


 


3.2
No-Action Letter. The Company agrees that it will be satisfied that no post-effective amendment or new registration
is required for the public sale of the Shares if it shall be presented with a letter from the Staff of the Securities and Exchange
Commission (the “Commission”), stating in effect that, based upon stated facts which the Company shall have no reason
to believe are not true in any material respect, the Staff will not recommend any action to the Commission if such Shares are
offered and sold without delivery of a prospectus, and that, therefore, no Registration Statement under which such shares are
to be registered is required to be filed.


 


3.3
Piggyback Registration. If the Company files a registration statement on Form S-3 for a third party after the Issue
Date of the Warrant, it will provide ten (10) days’ written notice to the Holder and give the Holder the opportunity for
a period of five (5) days after the notice period to include the Shares issuable upon exercise of the Warrant in such registration
statement. If the party for whom the Company is filing the registration statement objects to the inclusion of the Shares, the
Holder will no right to include the Shares in the registration statement.


 


3.4
Agreements. The agreements in this Section shall continue in effect regardless of the exercise and surrender
of this Warrant.


 


4.
Reservation of Shares. The Company shall
at all times reserve, for the purpose of issuance on exercise of this Warrant such number of shares of Common Stock or such class
or classes of capital stock or other securities as shall from time to time be sufficient to comply with this Warrant and the Company
shall take such corporate action as may, in the opinion of its counsel, be necessary to increase its authorized and unissued Common
Stock or such other class or classes of capital stock or other securities to such number as shall be sufficient for that purpose.


 




    	-7-



    	 



    

 


5.
Survival. All agreements, covenants, representations
and warranties herein shall survive the execution and delivery of this Warrant and any investigation at any time made by or on
behalf of any parties hereto and the exercise, sale and purchase of this Warrant (and any other securities or property) issuable
on exercise hereof.


 


6.
Remedies. The Company agrees that the
remedies at law of the Holder, in the event of any default or threatened default by the Company in the performance or compliance
with any of the terms of this Warrant, may not be adequate and such terms may, in addition to and not in lieu of any other remedy,
be specifically enforced by a decree of specific performance of any agreement contained herein or by an injunction against a violation
of any of the terms hereof or otherwise.


 


7.
Representations and Warranties by the Holder.
The Holder, by its acceptance of this Warrant, represents and warrants to the Company as follows:


 


7.1
This Warrant and the Shares issuable upon exercise thereof are being acquired for its own account, for investment and not with
a view to, or for resale in connection with, any distribution or public offering thereof within the meaning of the Act. Upon exercise
of this Warrant, the Holder shall, if so requested by the Company, confirm in writing, in a form satisfactory to the Company,
that the securities issuable upon exercise of this Warrant are being acquired for investment and not with a view toward distribution
or resale;


 


7.2
The Holder understands that the Warrant and the Shares have not been registered under the Act or any applicable state securities
laws by reason of their issuance in a transaction exempt from the registration and prospectus delivery requirements of the Act
pursuant to Section 4(2) thereof, and that they must be held by the Holder indefinitely, and that the Holder must therefore bear
the economic risk of such investment indefinitely, unless a subsequent disposition thereof is registered under the Act or any
applicable state securities laws or is exempted from such registration;


 


7.3
The Holder has such knowledge and experience in financial and business matters that it is capable of evaluating the merits and
risks of the purchase of this Warrant and the Shares purchasable pursuant to the terms of this Warrant and of protecting its interests
in connection therewith;


 


7.4
The Holder is able to bear the economic risk of the purchase of the Shares pursuant to the terms of this Warrant; and


 


7.5
The Holder is an “accredited investor” as such term is defined in Rule 501 of Regulation D promulgated under the Act.


 


8.
Other Matters.


 


8.1
Binding Effect. All the covenants and provisions of this Warrant by or for the benefit of the Company shall
bind and inure to the benefit of its successors and assigns hereunder.


 


8.2
Notices. All notices or demands provided for in this Warrant shall be validly given if in writing and delivered
personally, sent by certified mail, postage prepaid, or sent via an express delivery service, such as Federal Express or United
Parcel Service, to one party by the other party to the address set forth in this Warrant or to such other address as each party
may from time to time designate in writing. The Company’s address is:


 




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Digital
Ally, Inc.


9705
Loiret Blvd.


Lenexa,
KS 66219


Attn:
President


 


Holder’s
address is set forth in the first paragraph of this Warrant.


 


8.3
Governing Law. The validity, interpretation and performance of this Warrant shall be governed by the laws
of the State of Nevada.


 


8.4
Parties Bound and Benefitted. Nothing in this Warrant expressed and nothing that may be implied from any
of the provisions hereof is intended, or shall be construed, to confer upon, or give to, any person or corporation other than
the Company and the Holder any right, remedy or claim under promise or agreement hereof, and all covenants, conditions, stipulations,
promises and agreements contained in this Warrant shall be for the sole and exclusive benefit of the Company and its successors
and of the Holder, its successors and, if permitted, its assignees.


 


8.5
Headings. The Article headings herein are for convenience only and are not part of this Warrant and shall
not affect the interpretation thereof.


 




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IN
WITNESS WHEREOF, this Warrant has been duly executed by the Company under its corporate seal as of December 23, 2019.


 


	 	DIGITAL
    ALLY, INC.
	 	 	 
	 	By:	 
	 	 	Stanton
    E. Ross
	 	Its:	President
    and Chief Executive Officer


 




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DIGITAL
ALLY, INC.


 


Assignment


 


FOR
VALUE RECEIVED, _____________________________________ hereby sells, assigns and transfers unto____________________________________________________________________________________________
the within Warrant and the rights represented thereby, and does hereby irrevocably constitute and appoint ______________________________________
Attorney, to transfer said Warrant on the books of the Company, with full power of substitution.


 


	Dated:	 	 	 	 
	 	 	 	 	 
	 	 	 	Signed:	 
	 	 	 	 	 
	 	 	 	Print
    Name:	 


 




    	 



    	 



    






 


Subscription
Form


 


Digital
Ally, Inc.


9705
Loiret Blvd.


Lenexa,
KS 66210


 


The
undersigned hereby irrevocably subscribes for the purchase of ________________ shares of Common Stock (the “Shares”),
pursuant to and in accordance with the terms and conditions of this Warrant, and herewith makes payment, covering the purchase
of the Shares, which should be delivered to the undersigned at the address stated below, and, if such number of Shares shall not
be all of the Shares purchasable hereunder, then a new Warrant of like tenor for the balance of the remaining Shares purchasable
under this Warrant be delivered to the undersigned at the address stated below.


 


The
undersigned agrees that: (1) the undersigned will not offer, sell, transfer or otherwise dispose of any such Shares, unless either
(a) a registration statement, or post-effective amendment thereto, covering such Shares have been filed with the Securities and
Exchange Commission pursuant to the Securities Act of 1933, as amended (the “Act”), and such sale, transfer
or other disposition is accompanied by a prospectus meeting the requirements of Section 10 of the Act forming a part of such registration
statement, or post-effective amendment thereto, which is in effect under the Act covering the Shares to be so sold, transferred
or otherwise disposed of, or (b) counsel to the Company satisfactory to the undersigned has rendered an opinion in writing and
addressed to the Company that such proposed offer, sale, transfer or other disposition of the Shares is exempt from the provisions
of Section 5 of the Act in view of the circumstances of such proposed offer, sale, transfer or other disposition; (2) the Company
may notify the transfer agent for its Common Stock that the certificates for the Common Stock acquired by the undersigned are
not to be transferred unless the transfer agent receives advice from the Company that one or both of the conditions referred to
in (1)(a) and (1)(b) above have been satisfied; and (3) the Company may affix the legend set forth in Section 3.1 of this Warrant
to the certificates for Shares hereby subscribed for, if such legend is applicable.


 


	Dated:	 	 	Signed:	 
	 	 	 	 	 
	 	 	 	Address: