Manas Petroleum Corp. - Exhibit 10.2 - Filed by newsfilecorp.com







	MANAS PETROLEUM CORPORATION 
	NONSTATUTORY STOCK OPTION AGREEMENT 
	(Investor Relations) 
	 
	 


THIS NONSTATUTORY STOCK OPTION AGREEMENT
(“Agreement”) is made and entered into as of the date set forth
below, by and between MANAS PETROLEUM CORPORATION, a Nevada corporation
(the “Company”), and the following consultant of the Company (herein,
“Optionee”): 

In consideration of the covenants herein set forth, the parties
hereto agree as follows: 

	1.
               Option Information.




	 	(a) 	Date of Option: 	November 23, 2011 
	 	 	 	 
	 	(b) 	Optionee: 	General Research GmbH 
	 	 	 	 
	 	(c) 	Number of Shares: 	500,000 
	 	 	 	 
	 	(d) 	Exercise Price: 	US$0.20 



	2.
             Acknowledgements.
	 	 	 
		(a) 	
      Optionee is providing investor relations services (the
      “Services”) to the Company pursuant to a written IR Consulting
      Agreement dated effective November 22, 2011 (the “Agreement”);
      and

	 	 	 
		(b) 	
      As an inducement to Optionee and pursuant to the
      Agreement, the Board has authorized the granting to Optionee of a stock
      option (the “Option”) to purchase shares of common stock of the
      Company (“Common Shares”) upon the terms and conditions hereinafter
      stated.

	 	 	 
	3.
              Shares; Price.


3.1        Subject to the
acceptance of the Agreement by the TSX Venture Exchange and such other
regulatory authorities having jurisdiction, the Company hereby grants to
Optionee the non-transferable right to purchase, upon and subject to the terms
and conditions herein stated, the number of Common Shares set forth in Section
1(c) above (the “Shares”) for cash at the price per Share set forth in
Section 1(d) above (the “Exercise Price”). 

4.        
 Stock Option Plan 

4.1        The terms of the
Option will be subject to the 2011 stock option plan (the “Plan”) of the
Company, as may from time to time be amended, and any inconsistencies between
this Agreement and the Plan, as the same may be from time to time amended, shall
be governed by the provisions of the Plan. Upon a written request to the
Company, the Company shall deliver a copy of the Plan to the Optionee. 




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5.        
 Term of Option. 

5.1        This Option shall
expire, and all rights hereunder to purchase the Shares shall terminate, five
(5) years from the date hereof or, if earlier, upon the date and for the reasons
specified in Sections 8 and 13 below. Nothing contained herein shall be
construed to interfere in any way with the right of the Company to terminate the
relationship between it and Optionee, or to increase or decrease the
compensation paid to Optionee, if any, from the rate in effect as of the date
hereof. 

6.         
Vesting of Option. 

6.1        Subject to the
provisions of Sections 8 and 13 hereof, this Option shall become exercisable in
four instalments over a period of twenty four months, with the first instalment
of 125,000 Shares vesting May 23, 2012, the second instalment of 125,000 Shares
vesting November 23, 2012, the third instalment of 125,000 shares vesting May
23, 2013 and the fourth instalment of 125,000 Shares vesting November 23, 2013.
The instalments shall be cumulative (i.e., this Option may be exercised, as to
any or all Shares covered by an instalment, at any time or times after an
instalment becomes exercisable and until expiration or termination of this
Option). 

7.         
Exercise. 

	7.1
             This Option shall be exercised by delivery to the Company
    of:
	 	 	 
		(a) 	
      written notice of exercise stating the number of Shares
      being purchased (in whole shares only) and such other information set
      forth on the form of Notice of Exercise attached hereto as Appendix
    A;

	 	 	 
		(b) 	
      a cashier’s cheque, bank draft, wire transfer (pursuant
      to wire transfer instructions that will be supplied by the Company upon
      request) or cash in the amount of the Exercise Price of the Shares covered
      by the notice; and

	 	 	 
		(c) 	
      a written investment representation as provided for in
      Section 13 hereof.



Except as otherwise expressly permitted in Section 8, below,
this Option shall not be assignable or transferable and may be exercised
only by Optionee. 

8.         
Death of Optionee. 

8.1        If Optionee shall
die while serving as a consultant of the Company, Optionee’s personal
representative or the person entitled to Optionee’s rights hereunder may at any
time within thirty (30) days after the date of Optionee’s death, or during the
remaining term of this Option, whichever is the lesser, exercise this Option and
purchase Shares to the extent, but only to the extent, that Optionee could have
exercised this Option as of the date of Optionee’s death; provided, in any case, that this Option may be so exercised
only to the extent that this Option has not previously been exercised by
Optionee. 




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9.          No
Rights as Shareholder. 

9.1        Optionee shall
have no rights as a shareholder with respect to the Shares covered by any
instalment of this Option until the effective date of the issuance of Shares
following exercise of this Option, and no adjustment will be made for dividends
or other rights for which the record date is prior to the date such stock
certificate or certificates are issued except as provided in Section 10 hereof.


10.       
Recapitalization. 

10.1      Subject to any required
action by the shareholders of the Company, the number of Shares covered by this
Option, and the Exercise Price thereof, shall be proportionately adjusted for
any increase or decrease in the number of issued Common Shares resulting from a
subdivision or consolidation of Common Shares or the payment of a stock
dividend, or any other increase or decrease in the number of such Common Shares
effected without receipt of consideration by the Company; provided however that
the conversion of any convertible securities of the Company shall not be deemed
having been “effected without receipt of consideration by the Company.” 

10.2      In the event of a proposed
dissolution or liquidation of the Company, a merger or consolidation in which
the Company is not the surviving entity, or a sale of all or substantially all
of the assets or capital stock of the Company (collectively, a
“Reorganization”), this Option shall terminate immediately prior to the
consummation of such proposed action, unless otherwise provided by the Board;
provided, however, if Optionee shall be a consultant of the Company at the time
such Reorganization is approved by the stockholders, Optionee shall have the
right to exercise this Option as to all or any part of the Shares, without
regard to the instalment provisions of Section 6, for a period beginning 30 days
prior to the consummation of such Reorganization and ending as of the
Reorganization or the expiration of this Option, whichever is earlier, subject
to the consummation of the Reorganization. In any event, the Company shall
notify Optionee, at least 30 days prior to the consummation of such
Reorganization, of his exercise rights, if any, and that the Option shall
terminate upon the consummation of the Reorganization. 

10.3      Subject to any required
action by the shareholders of the Company, if the Company shall be the surviving
entity in any merger or consolidation, this Option thereafter shall pertain to
and apply to the securities to which a holder of Common Shares equal to the
Shares subject to this Option would have been entitled by reason of such merger
or consolidation, and the instalment provisions of Section 6 shall continue to
apply. 

10.4      In the event of a change in
the Common Shares of the Company as presently constituted, which is limited to a
change of all of its authorized Common Shares without par value into the same
number of Common Shares with a par value, the shares resulting from any such
change shall be deemed to be the Shares within the meaning of this Option. 

10.5      To the extent that the
foregoing adjustments relate to Common Shares or securities of the Company, such
adjustments shall be made by the Board, whose determination in that respect shall be final, binding and conclusive. Except as hereinbefore
expressly provided, Optionee shall have no rights by reason of any subdivision
or consolidation of Common Shares of any class or the payment of any stock
dividend or any other increase or decrease in the number of shares of stock of
any class, and the number and price of Shares subject to this Option shall not
be affected by, and no adjustments shall be made by reason of, any dissolution,
liquidation, merger, consolidation or sale of assets or capital stock, or any
issue by the Company of shares of stock of any class or securities convertible
into shares of stock of any class. 




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10.6      The grant of this Option
shall not affect in any way the right or power of the Company to make
adjustments, reclassifications, reorganizations or changes in its capital or
business structure or to merge, consolidate, dissolve or liquidate or to sell or
transfer all or any part of its business or assets. 

11.        Taxation upon
Exercise of Option. 

11.1      Optionee understands that,
upon exercise of this Option, Optionee may, depending on applicable tax laws in
the jurisdiction where Optionee is liable for the payment of income taxes,
recognize income, for income tax purposes, in an amount equal to the amount by
which the fair market value of the Shares, determined as of the date of
exercise, exceeds the Exercise Price. The acceptance of the Shares by Optionee
shall constitute an agreement by Optionee to report such income in accordance
with then applicable law and to cooperate with the Company in establishing the
amount of such income and corresponding deduction to the Company for its income
tax purposes. Withholding for federal or state income and employment tax
purposes will be made, if and as required by law, from Optionee’s then current
compensation, or, if such current compensation is insufficient to satisfy
withholding tax liability, the Company may require Optionee to make a cash
payment to cover such liability as a condition of the exercise of this Option.


12.        Modification,
Extension and Renewal of Options. 

12.1      The Board may modify, extend
or renew this Option or accept the surrender thereof (to the extent not
theretofore exercised) and authorize the granting of a new option in
substitution therefor (to the extent not theretofore exercised), subject at all
times to the applicable rules of any regulatory authority or stock exchange, and
any applicable laws. Notwithstanding the foregoing provisions of this Section
12, no modification shall, without the consent of Optionee, materially alter to
Optionee’s detriment or materially impair any rights of Optionee hereunder. 

	13.
             TSX Venture Exchange
	 	 	 
		
      If and for so long as any of the Company’s securities are
      listed for trading on the TSX Venture Exchange (the “TSXV”), the
      provisions of this Section 13 will apply to this Agreement and to any
      Options granted hereunder. To the extent that the provisions of this
      Section are inconsistent with the provisions found in the other Sections
      of this Agreement, the provisions of this Section will prevail.

	 	 	 
		13.1 	
      The term “consultant”, “consultant company” and
      “management company employee” will have the meanings as defined in the
      applicable policy of the TSXV. As a condition precedent to the issuance of
      an Option, the Company must be able to represent to the TSXV as of the grant date
      that Optionee is a bona fide consultant or management company
      employee, as the case may be.








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	 	13.2 	
      The exercise price of an Option must be paid in
    cash.

	 	 	 	 
	 	13.3 	
      Options and Shares will be subject to all applicable
      trading restrictions in effect pursuant to TSXV policies and the Company
      shall be entitled to legend any Option certificates and the certificates
      representing Shares issued upon exercise of Options accordingly, including
      TSXV legends, as applicable.

	 	 	 	 
	 	13.4 	
      In the event of Optionee’s death, any Options held by
      Optionee shall pass to the personal representative (being the executor or
      administrator of the deceased option holder, duly appointed by a court or
      public authority having jurisdiction to do so) of Optionee and shall be
      exercisable by the personal representative on or before the date which is
      the earlier of twelve months following the date of death and the
      applicable expiry date.

	 	 	 	 
	 	13.5 	
      Options granted hereunder shall expire on the date that
      is 30 days after the arrangement with Optionee to provide services expires
      or is terminated.

	 	 	 	 
	 	13.6 	
      The Company shall establish, and Optionee shall comply
      with, procedures to monitor any trading in Common Shares of the Company by
      Optionee or any of Optionee’s affiliates or associates (as those terms are
      defined by the TSXV). By way of example, these procedures may include the
      establishment of a designated brokerage account through with Optionee and
      its affiliates or associates conduct all trades in Common Shares of the
      Company, or the requirement that these persons file insider trading
      reports with the Company.

	 	 	 	 
	 	13.7 	
      The Options granted hereunder are subject to approval by
      a majority of the Company’s disinterested shareholders at a meeting of the
      shareholders if this Agreement would result at any time in:

	 	 	 	 
	 		i. 	
      the number of Common Shares reserved for issuance
      pursuant to all stock options granted to “Insiders” (as that term is
      defined under applicable law), including those granted pursuant to this
      Agreement, exceeding ten percent (10%) of the issued and outstanding
      Common Shares of the Company; or

	 	 	 	 
	 		ii. 	
      the grant to Insiders, within a 12 month period, of a
      number of options, including those granted pursuant to this Agreement,
      exceeding ten percent (10%) of the issued and outstanding Common Shares of
      the Company; or

	 	 	 	 
	 		iii. 	
      the issuance to any one person, including Optionee,
      within a 12 month year period, of a number of Common Shares exceeding five
      percent (5%) of the issued and outstanding Common Shares of the
      Company.



13.8      If Optionee is not an
individual, Optionee shall complete and file with TSXV a Certification and
Undertaking Required from a Company Granted an Incentive Stock Option (Form
4F), as described in Sections 2.5 and 4.2 of TSXV Policy 4.4 as in
effect on the date of this Agreement and as the same may be amended from
time-to-time. 




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13.9      Optionee shall complete and
file a Personal Information Form (Form 2A) or, if applicable, a
Statutory Declaration (Form 2C1) with TSXV. 

14.      
 Representations and Warranties 

14.1      Optionee authorizes the
Company to represent and warrant to the TSXV that Optionee is a “consultant” of
the Company (as that term is defined in Section 1.2 of TSXV Policy 4.4 as is in
effect on the date of this Agreement and as the same may be amended from
time-to-time). 

14.2      If on the date of this
Agreement or on the date of exercise of any of the Options granted hereunder,
Optionee is a U.S. Person (as defined in Rule 902 of Regulation S, promulgated
by the Securities and Exchange Commission) or is physically located in the
United States, Optionee represents and agrees that: 

	 	(a) 	
      if and when Optionee exercises this Option in whole or in
      part, Optionee will in each case acquire the Shares upon such exercise for
      the purpose of investment and not with a view to, or for resale in
      connection with, any distribution thereof; and that upon such exercise of
      this Option in whole or in part, Optionee (or any person or persons
      entitled to exercise this Option under the provisions of Section 8 hereof)
      shall furnish to the Company a written statement to such effect,
      satisfactory to the Company in form and substance. If the Shares
      represented by this Option are registered under the Securities Act of
      1933, as amended (the “Securities Act”) either before or after
      the exercise of this Option in whole or in part, Optionee shall be
      relieved of the foregoing investment representation and agreement and
      shall not be required to furnish the Company with the foregoing written
      statement;

	 	 	 
	 	(b) 	
      that Optionee has had access to the financial statements
      of the Company, has had the opportunity to ask questions of the Company
      concerning its business, operations and financial condition, and to obtain
      additional information reasonably necessary to verify the accuracy of such
      information (collectively, the “Company Information”). Optionee
      understands that all of the Company Information is available for
      Optionee’s review on both the EDGAR database maintained by the Securities
      and Exchange Commission (as www.sec.gov) and the SEDAR database maintained
      by the Canadian Securities Administrators (at www.sedar.com);

	 	 	 
	 	(c) 	
      that Optionee has sufficient education and experience as
      will enable Optionee to review and understand the Company Information and
      is able to assess the merits and the risks of an investment in the Company
      and its business; and

	 	 	 
	 	(d) 	
      that all information contained in the Questionnaire is
      complete and accurate and Optionee understands and agrees that the Company
      and others will rely upon the truth and accuracy of the acknowledgements,
      representations and agreements contained in this Agreement and the
      Questionnaire, and agrees that if any of such acknowledgements, representations and
agreements are no longer accurate or have been breached, Optionee shall promptly
notify the Company. 








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14.3      The securities deliverable
upon exercise of this Option may be subject to restrictions on resale under
applicable securities laws and the policies of any stock exchange or market on
which the Company’s securities may be traded or listed for quotation from
time-to-time. Optionee agrees that the Company may take such steps as the
Company deems reasonably necessary to comply with applicable law and the
requirements of any stock exchange and, promptly after receipt of any request
from the Company, acting reasonably, Optionee shall cooperate with the Company
in providing information to regulatory authorities, filing required reports and
similar compliance efforts. 

14.4      Unless and until the Shares
represented by this Option are registered under the Securities Act, all
certificates representing the Shares and any certificates subsequently issued in
substitution therefor and any certificate for any securities issued pursuant to
any stock split, share reclassification, stock dividend or other similar capital
event shall bear legends in substantially the following form: 

THESE SECURITIES HAVE NOT BEEN REGISTERED WITH THE
SECURITIES AND EXCHANGE COMMISSION OR THE UNITED STATES SECURITIES COMMISSION OF
ANY STATE AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION
UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND,
ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE
REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE
EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE
SECURITIES LAWS. IN ADDITION, HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY
NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE SECURITIES ACT. 

and/or such other legend or legends as the Company and its
counsel deem necessary or appropriate including, where applicable, any legend
required by the Canadian securities laws or any stock exchange on which
securities of the Company are traded. Appropriate stop transfer instructions
with respect to the Shares have been placed with the Company’s transfer agent.


15.        Stand-off
Agreement. 

15.1      Optionee agrees that, in
connection with any registration of the Company’s securities under the
Securities Act, and upon the request of the Company or any underwriter managing
in an underwritten offering of the Company’s securities, Optionee shall not
sell, short any sale of, loan, grant an option for, or otherwise dispose of any
of the Shares (other than Shares included in the offering) without the prior
written consent of the Company or such managing underwriter, as applicable, for
a period of at least one year following the effective date of registration of
such offering. 




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16.        Notices.


16.1      Any notice required to be
given pursuant to this Option shall be in writing and shall be deemed to be
delivered upon receipt or, in the case of notices by the Company, five (5) days
after deposit in the mail, postage prepaid, addressed to Optionee at the address
last provided by Optionee to the Company. 

17.        Independent
Legal Advice 

	17.1 	
      Optionee acknowledges that:

	 	 	 
		(a) 	
      this Agreement was prepared by Clark Wilson LLP who is
      solely representing the Company;

	 	 	 
		(b) 	
      Clark Wilson LLP received instructions from the Company
      and does not represent Optionee;

	 	 	 
		(c) 	
      Optionee has been requested to obtain his own independent
      legal advice. including tax advice;

	 	 	 
		(d) 	
      Optionee has been given adequate time to obtain
      independent legal advice;

	 	 	 
		(e) 	
      by signing this Agreement, Optionee confirms that he
      fully understands this Agreement; and

	 	 	 
		(f) 	
      by signing this Agreement without first obtaining
      independent legal advice, Optionee waives his right to obtain legal
      advice.

	 	 	 
	18. 	
      Applicable Law.



18.1      The interpretation and
enforcement of this Option Agreement and any questions with respect to the
validity of any Options granted hereunder shall be governed by the laws of the
State of Nevada and, to the extent applicable, the federal laws of the United
States and the securities laws of any state or province of the United States or
Canada having jurisdiction over the Company. 

[SIGNATURE PAGE FOLLOWS.] 




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IN WITNESS WHEREOF, the parties hereto have executed
this Option as of the date first above written. 

	COMPANY: 		MANAS PETROLEUM
      CORPORATION, 
	  	 	a Nevada
    corporation
	  	  	  
	  	  	  
	  	By: 	  
	  	Name: 	Peter-Mark Vogel 
	  	Title: 	Chief Executive Officer 
	  	  	  
	OPTIONEE: 		GENERAL RESEARCH
      GMBH 
	  	  	  
	  	  	  
	  	By: 	  
	  	Name: 	Dr. Georg Hochwimmer 
	  	Title: 	Managing Director 






APPENDIX A 

NOTICE OF EXERCISE 

MANAS PETROLEUM CORPORATION 

Re:   Nonstatutory Stock Option 

Notice is hereby given pursuant to Section 7 of my Nonstatutory
Stock Option Agreement that I elect to purchase the number of shares set forth
below at the exercise price set forth in my option agreement: 

Nonstatutory Stock Option Agreement
dated: ________________

Number of shares being purchased:
________________

Exercise Price: $________________

A check in the amount of the aggregate
price of the shares being purchased is attached. 

I hereby confirm that such shares (the “Option Shares”)
are being acquired by me for my own account for investment purposes, and not
with a view to, or for resale in connection with, any distribution thereof. I
will not sell or dispose of my Shares in violation of the Securities Act of
1933, as amended, or any applicable federal, state or provincial securities
laws. 

I represent that, at the time of exercise of my Stock Option,
all of the representations and warranties contained in my Stock Option
Agreement, and any certificates, questionnaires, or other instruments attached
thereto, are true and accurate. 

I understand that the certificate representing the Option
Shares will bear a restrictive legend within the contemplation of the Securities
Act and as required by such other state, provincial or federal law or regulation
applicable to the issuance or delivery of the Option Shares. 

I agree to provide to the Company such additional documents or
information as may be required pursuant to my Stock Option Agreement. 

	 	By: 	 
	 	 	(signature) 
	 	 	  
	 	Name: 	 






APPENDIX B 

ACCREDITED INVESTOR QUESTIONNAIRE 

(TO BE COMPLETED IF OPTIONEE IS A U.S. PERSON AT THE DATE OF
GRANT OR AT THE DATE OF EXERCISE OF THE OPTIONS) 

All capitalized terms herein, unless otherwise defined, have
the meanings ascribed thereto in the Stock Option Agreement. 

Optionee covenants, represents and warrants to the Company that
he satisfies one or more of the categories of “Accredited Investors”, as defined
by Regulation D promulgated under the Securities Act, as indicated below:
(Please initial in the space provide those categories, if any, of an “Accredited
Investor” which Optionee satisfies) 

		_________  Category 1 	 	
      An organization described in Section 501(c)(3) of the
      United States Internal Revenue Code, a corporation, a Massachusetts or
      similar business trust or partnership, not formed for the specific purpose
    of acquiring the Units, with total assets in excess of US $5,000,000;    

	 	  	 	
       

		_________  Category 2 	 	
      A natural person whose individual net worth, or joint net
      worth with that person’s spouse, on the date of purchase exceeds US
      $1,000,000, excluding the value of the primary residence of such natural
      person, calculated by subtracting from the estimated fair market value of
      the property the amount of debt secured by the property, up to the
      estimated fair market value of the property; 

	 	  	 	
       

		_________  Category 3 	 	
      A natural person who had an individual income in excess
      of US $200,000 in each of the two most recent years or joint income with
      that person’s spouse in excess of US $300,000 in each of those years and
      has a reasonable expectation of reaching the same income level in the
      current year; 

	 	  	 	
       

		_________  Category 4 	 	
      A “bank” as defined under Section (3)(a)(2) of the
      Securities Act or savings and loan association or other institution as
      defined in Section 3(a)(5)(A) of the Securities Act acting in its
      individual or fiduciary capacity; a broker dealer registered pursuant to
      Section 15 of the Securities Exchange Act of 1934 (United States);
      an insurance company as defined in Section 2(13) of the Securities Act; an
      investment company registered under the Investment Company Act of
      1940 (United States) or a business development company as defined in
      Section 2(a)(48) of such Act; a Small Business Investment Company licensed
      by the U.S. Small Business Administration under Section 301(c) or (d) of
      the Small Business Investment Act of 1958 (United States); a
      plan with total assets in excess of $5,000,000 established and maintained
      by a state, a political subdivision thereof, or an agency or
      instrumentality of a state or a political subdivision thereof, for the
      benefit of its employees; an employee benefit plan within the meaning of
      the Employee Retirement Income Security Act of 1974 (United States)
      whose investment decisions are made by a plan fiduciary, as defined in
      Section 3(21) of such Act, which is either a bank, savings and loan
      association, insurance company or registered investment adviser, or if the
      employee benefit plan has total assets in excess of $5,000,000, or, if a
      self- directed plan, whose investment decisions are made solely by persons
      that are accredited investors; 

	 	  	 	
       

		_________  Category 5 	 	
      A private business development company as defined in
      Section 202(a)(22) of the Investment Advisers Act of 1940 (United
      States); 








- 2 - 

	 	_________  Category 6 	 	
  A director or executive officer of the Company;

	 	  	 	
      

	 	_________  Category 7 	 	
      A trust with total assets in excess of $5,000,000, not
      formed for the specific purpose of acquiring the Securities, whose
      purchase is directed by a sophisticated person as described in Rule
      506(b)(2)(ii) under the Securities Act; 

	 	  	 	
      

	 	_________  Category 8 	 	
      An entity in which all of the equity owners satisfy the
requirements of one or more of the foregoing categories;



Optionee hereby certifies that the information contained in
this Questionnaire is complete and accurate and Optionee will notify the Company
promptly of any change in any such information. 

IN WITNESS WHEREOF, the undersigned has executed this
Questionnaire as of the _______day of __________________, 20__. 

	 	X
  
	 	Signature 
	 	 
	 	 
	 	Print or Type Name 
	 	 
	 	 
	 	Social Security/Tax I.D. No.