Document:

EXHIBIT
      10.35

    

     

    MEDSTRONG
      INTERNATIONAL CORPORATION

    255
      N.E.
      6th
      Avenue

    Delray
      Beach, FL 33483

     

    February
      6, 2007

    

    

    RALEIGH
      MARKETING COMMUNICATIONS, INC.

    Attn:
      Mr.
Timothy
      J. Raleigh

    473
      Maple
      Avenue 

    Oakville,
      Ontario L6J 2J2 CANADA

    

    Dear
      Mr.
      Raleigh: 

    

    Reference
      is made to that certain Consulting Services Agreement (the “Agreement”) entered
      into between RALEIGH MARKETING COMMUNICATIONS, INC. (“Consultant”) and MEDSTRONG
      INTERNATIONAL CORPORATION (the “Company”). All capitalized terms in this letter
      that are not otherwise defined shall be as defined in the Agreement. Pursuant
      to
      the Agreement, Consultant has agreed to provide consulting services with respect
      to the technology/product development of the Company. The Agreement provides
      in
      Section 1(b) that we will mutually agree upon the basis upon which the Services
      would be performed. Further, the Agreement provides in Section 2(c) that we
      will
      mutually agree upon the manner in which Consultant will be paid. This letter
      represents the mutual agreement between us in regards to the above
      matters.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    In
      regards to Section 1(b), Consultant and Company agree that Consultant shall
      render the Services on a full time basis at the Company's principal place of
      business, other Company locations, or at other places upon mutual agreement
      of
      the parties. In regards to Section 2(c), Consultant
      hereby agrees to defer receipt of consulting fees identified in Section 2(a),
      and Company agrees to accrue such fees, until such time that: (i) the Company
      receives funding from any source and
      (ii) the
      senior executives of the Company (who are deferring their salaries) are paid
      their accrued compensation as determined by the Company’s Board of Directors. At
      such times that the foregoing conditions are met, Consultant shall be repaid
      its
      accrued compensation to the same extent that such accrued compensation is repaid
      to the Company’s senior executives. Until the deferred/accrued consulting fees
      are paid pursuant to the above, Consultant’s
      monthly statements will identify the aggregate amount of deferred fees that
      are
      accruing. After such fees are paid, the Company will subsequently pay Consultant
      the amounts indicated in each monthly statement within ten (10) business
      days.

    

    Except
      as
      provided the above, the terms and conditions of the Agreement are otherwise
      unchanged.

    

    Provided
      the terms of this letter accurately reflect the mutual agreement between us,
      please sign and return the enclosed copy. 

    

    Sincerely
      yours,

     

    
      	MEDSTRONG INTERNATIONAL CORPORATION	 	 	 
	 	 	 	 
	By:
 /s/
              Stephen Bartkiw	 	 	 
	
              
                

              

              Name/Title: Stephen Bartkiw, CEO

            	 	 	
               

            

    

     

     

    
      	
              Agreed:

              

              RALEIGH
                MARKETING COMMUNICATIONS, INC.

            	 
	 	 	 	 
	By:  /s/
              Tim Raleigh	 	 	 
	
              
                

              

              Name/Title: Timothy J. Raleigh,
                PresidentEXHIBIT
      10.36

    

    OFFICE
      LEASE AGREEMENT

    

    This
      Office Lease Agreement (this “Lease”) is made and entered into as of January 8,
      2007 (the “Effective Date”), by and between TRACKSIDE BROTHERS LLC, a Florida
      limited liability company (“Landlord”), and MEDSTRONG INTERNATIONAL CORPORATION,
      a Delaware corporation (“Tenant”). 

    

    BASIC
      TERMS 

    

    The
      following terms (“Basic Terms”) are hereby incorporated into and made a part of
      this Lease. Each reference in this Lease to the Basic Terms shall mean the
      information set forth below and shall be construed to incorporate all of the
      terms provided under the particular section in this Lease pertaining to such
      information. In the event of a conflict between the Basic Terms and the
      particular section in this Lease, the particular section shall prevail.

     

     

    1.   Landlord:   Trackside
      Brothers LLC, a Florida limited liability company

    313
      N.E.
      3rd Street

    Delray
      Beach, FL 33444

     

    2.   Tenant:   Medstrong
      International Corporation, a Delaware corporation

    255
      N.E.
      6th Avenue

    Delray
      Beach, FL 33483

     

    3.   Leased
      Premises:   Approximately
      3,000 square feet of office space in a building containing an aggregate of
      7,388
      square feet (40% of the space).

     

    4.   Term:   Twelve
      (12) months with a right to renew for an additional twelve (12) months with
      a 4%
      increase in Base Rent for the renewal year

     

    5.   Base
      Rent:   Tenant
      shall pay $15 per square foot per annum ($3750 per month), increased by 4%
      (if
      term is renewed). 

     

    6.   Operating
      Expenses:   Tenant
      shall pay 40% of the Operating Expenses.*

     

    8.  
       Security
      Deposit:     None

     

    7.   Termination:   Tenant
      may terminate at any time with 30 days written notice and payment of one-month’s
      rent as termination fee.

    

    OFFICE
      LEASE AGREEMENT

    

    1) Lease
      of
      Premises: Landlord, for and in consideration of the rents, covenants and
      agreements hereinafter set forth, hereby leases to Tenant and Tenant hereby
      leases from Landlord the office space located in the premises situated in the
      city of Delray Beach, County of Palm Beach, State of Florida, described as:
      3,000 square feet of office space within a 7,388 square foot mixed use building
      (comprising 40% of the total space) located at 255 N.E. 6th Avenue, Delray
      Beach, FL 33483 (the “Leased Premises”)

    

    2) Term:
      Landlord agrees to lease to Tenant the above premises for a term of twelve
      (12)
      months commencing January 8, 2007 and terminating on January 7, 2008 as provided
      herein. 

    

    3) Rent
      and
      Operating Expenses; Deferral: 

     

    a) Base
      Rent: Subject to paragraph (c) below, Tenant shall pay to Landlord a monthly
      rental of $3,750 (an amount equal to $15 per square foot per year comprising
      the
      Leased Premises) payable in advance on the 8th day of each and every calendar
      month thereafter in advance.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    b) Operating
      Expenses: Subject to paragraph (c) below:

    

    i) Tenant
      shall pay to Landlord its pro rata share of the expenses incurred by Landlord
      with respect to the ownership, maintenance and operation of the Property, namely
      utilities charges (expressly excluding telephone and network expenses), taxes,
      day-to-day maintenance and insurance premiums (“Operating Expenses”). The Leased
      Premises comprise forty percent (40%) of the building. Based on the Operating
      Expenses of 2006 (which totaled $65,028), Tenant’s pro rata share (i.e., 40%) of
      total Operating Expenses is estimated at $23,400 for calendar year 2007. Tenant
      shall pay the estimated amount of Operating Expenses for the first year of
      the
      Term in monthly installments of $1,950, in advance, on the 8th day of each
      month
      during the term.

    

    ii) At
      the
      end of the term, Landlord shall determine the actual amount of Operating
      Expenses and Tenant’s prorata share thereof and deliver a written statement of
      the amount thereof to Tenant. If Tenant paid less than the amounts specified
      in
      said certification, Tenant shall pay the unpaid portion of the same within
      ten
      (10) days after receipt of such certification. In turn, if Tenant paid more
      than
      the amounts specified in said certification, Landlord shall reimburse Tenant
      the
      amount in excess within ten (10) days after receipt of such
      certification.

    

    iii) The
      Operating Expenses exclude telephone and network expenses. Tenant shall be
      financially responsible for all telephone and network expenses (“Telephone
      Expenses”) relating to the conduct of its business. Telephone Expenses may be
      billed directly to Tenant or to Landlord by the applicable provider; in the
      latter case, unless otherwise mutually agreed, Landlord shall pay the billed
      Telephone Expense and thereupon bill Tenant for such Telephone Expense. Tenant
      shall reimburse Landlord for paying the Telephone Expense within fifteen (15)
      business days of receiving the bill from Landlord.

    

    c) Deferral
      and Accrual of Base Rent and Operating Expenses: Unless otherwise agreed to
      in
      writing by the parties, notwithstanding paragraphs (a) and (b) above, Landlord
      hereby agrees to defer and accrue the payment of Base Rent, Operating Expenses
      and Telephone Expenses (that Landlord has paid) until such time that: (i) Tenant
      receives financing from any source, (ii) Tenant’s employees and consultants (who
      are also deferring their salaries and/or fees) are fully paid their accrued
      compensation/fees, and (iii) Tenant has sufficient funding to pay Landlord
      as
      determined by Tenant’s Board of Directors. At such time that the foregoing
      conditions are met, Tenant agrees to pay Landlord the accrued Base Rent,
      Operating Expenses and Telephone Expenses payments identified in paragraphs
      (a)
      and (b); once the accrued amounts have been fully paid, Tenant shall make
      subsequent payments in accordance with this Lease.

    

    d) Tax
      on
      Rent and Expenses: Tenant shall pay to Landlord any sales tax or excise tax
      on
      rents which is levied or assessed by the State of Florida or any political
      subdivision thereof (e.g. county) against Landlord in respect to its Base Rent,
      Operating Expenses and Telephone Expenses payments.

    

    e) Delivery
      of Payments: All rental payments shall be made to Landlord, at Landlord’s office
      as follows: 313 N.E. 3rd Street, Delray Beach, FL 33444.

    

    f) Security
      Deposit: No security deposit shall be required by Landlord.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    4) Use:
      

    

    a) General:
      Tenant shall use and occupy the premises as general offices to conduct its
      business operations. The premises shall be used for no other purpose. Landlord
      represents that the premises may lawfully be used for such purpose.

    

    b) Parking:
      Tenant shall have a right to use the parking spaces located at the property.
      Such parking spaces shall be provided to Tenant at no charge throughout the
      term
      of this Lease.

    

    5) Care
      and
      Maintenance of Premises: Tenant acknowledges that the premises are in good
      order
      and repair, unless otherwise indicated herein. Tenant shall, at Tenant(s) own
      expense and at all times, maintain the premises in good and safe condition
      and
      shall surrender the same at termination hereof, in as good condition as
      received, normal wear and tear excepted. Tenant shall be responsible for all
      repairs required, excepting any material structural and equipment repairs such
      as by way of example the Leased Premises’ roof, exterior walls, and structural
      foundations, as well as the property’s HVAC plumbing and electrical
      systems.

    

    6) Ordinances
      and Statutes: Tenant shall, at Tenant's sole cost, comply with all statutes,
      ordinances and requirements of all municipal, state and federal authorities
      now
      in force, pertaining to the use of said premises and shall faithfully observe
      in
      said use all municipal ordinances, state and federal statutes now in force
      or
      which may hereafter be in force and observe and maintain all Environmental
      standards. 

    

    7) Assignment
      and Subletting: Tenant shall not assign this lease or sublet any portion of
      the
      premises without prior written consent of the Landlord, in its sole discretion.
      Any such assignment or subletting without consent shall be void and at the
      option of the Landlord, may terminate this lease.

    

    8) Utilities:
      All applications and connections for necessary utility services on the demised
      premises shall be made in the name of Landlord, and Tenant shall be liable
      for
      its pro-rata share of the utility charges (including those for sewer, water,
      gas, electricity and telephone services) as Operating Expenses in accordance
      with Section 3(b) above. 

    

    9) Entry
      and
      Inspection: Tenant shall permit Landlord or Landlord's agents to enter upon
      the
      premises at reasonable times and upon reasonable notice, for the purpose of
      inspecting the same and shall permit Landlord at any time within sixty days
      prior to the expiration of this lease, to place upon the premises any usual
“For
      Sale”, “To Let” or “For Lease” signs and permit persons desiring to lease the
      same to inspect the premises thereafter. 

    

    10) Alterations:
      Tenant shall not, without first obtaining the written consent of Landlord,
      make
      any alterations, additions or improvements, in, to or about the premises.
      NOTHING IN THIS LEASE SHALL BE DEEMED TO BE, OR CONSTRUED IN ANY WAY AS
      CONSTITUTING, THE CONSENT OR REQUEST OF LANDLORD, EXPRESSED OR IMPLIED, BY
      INFERENCE OR OTHERWISE, TO ANY PERSON, FIRM OR CORPORATION FOR THE PERFORMANCE
      OF ANY LABOR OR THE FURNISHING OF ANY MATERIALS FOR ANY CONSTRUCTION,
      REBUILDING, ALTERATION OR REPAIR OF OR TO THE PREMISES OR ANY PART THEREOF,
      NOR
      AS GIVING TENANT ANY RIGHT, POWER OR AUTHORITY TO CONTRACT FOR OR PERMIT THE
      RENDERING OF ANY SERVICES OR THE FURNISHING OF ANY MATERIALS WHICH MIGHT IN
      ANY
      WAY GIVE RISE TO THE RIGHT TO FILE ANY LIEN AGAINST THE BUILDING OR LANDLORD’S
      INTEREST IN THE PREMISES. TENANT SHALL NOTIFY ANY CONTRACTOR PERFORMING ANY
      CONSTRUCTION WORK IN THE PREMISES ON BEHALF OF TENANT THAT THIS LEASE
      SPECIFICALLY PROVIDES THAT THE INTEREST OF LANDLORD IN THE PREMISES SHALL NOT
      BE
      SUBJECT TO LIENS FOR IMPROVEMENTS MADE BY TENANT, AND NO MECHANIC’S LIEN OR
      OTHER LIEN FOR ANY SUCH LABOR, SERVICES, MATERIALS, SUPPLIES, MACHINERY,
      FIXTURES OR EQUIPMENT SHALL ATTACH TO OR AFFECT THE STATE OR INTEREST OF
      LANDLORD IN AND TO THE PREMISES, THE BUILDING, OR ANY PORTION THEREOF. IN
      ADDITION, LANDLORD SHALL HAVE THE RIGHT TO POST AND KEEP POSTED AT ALL
      REASONABLE TIMES ON THE PREMISES ANY NOTICES WHICH LANDLORD SHALL BE REQUIRED
      SO
      TO POST FOR THE PROTECTION OF LANDLORD AND THE PREMISES FROM ANY SUCH LIEN.
      TENANT AGREES TO PROMPTLY EXECUTE SUCH INSTRUMENTS IN RECORDABLE FORM IN
      ACCORDANCE WITH THE TERMS AND PROVISIONS OF FLORIDA STATUTE 713.10.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    11) Indemnification
      of Landlord: Landlord shall not be liable for any loss, damage or injury of
      any
      kind, to any person, including Tenant, Tenant(s) family and Tenant(s) visitors
      or property arising from any use of the Leased Premises, any part thereof or
      caused by any defect in any structure, facility or other improvements thereon
      or
      therein or caused by or arising from any act or omission of Tenant, Tenant(s)
      family, Tenant(s) visitors or any other person or by or from an accident on
      the
      premises or any fire or other casualty or occasioned by the failure of Tenant
      to
      maintain or repair the Leased Premises or by Tenant(s) breach of any obligation
      under this Lease. 

    

    12) Insurance:
      

    

    a) Landlord:
      Landlord shall keep the Property insured for the benefit of Landlord, its
      lenders and agents, in an amount in Landlord’s sole discretion which may
      include: 

    

    i) loss
      or
      damage by fire; and 

    

    ii) such
      other risk or risks which are customarily covered with respect to buildings
      and
      improvements similar in construction, general location, use, occupancy and
      design to the Property, including but not limited to windstorms hail, explosion,
      vandalism, malicious mischief civil commotion and such other coverage as
      Landlord may deem appropriate or necessary. 

    

    Tenant
      acknowledges and accepts that Landlord may self-insure all or a potion of the
      Building, Land, Property or Premises. 

    

    b) Tenant:
      Tenant, at Tenant(s) sole cost and expense, but for the mutual benefit of
      Landlord and Tenant, shall maintain commercial liability insurance, including
      liability against claims for personal injury, death or property damage occurring
      in, upon or about the premises and on any sidewalks directly adjacent to the
      premises. All such policies of insurance shall be issued in the name of the
      Tenant, with the Landlord named as additional insured. 

    

    13) Eminent
      Domain: If the premises or any part thereof or any estate therein or any other
      part of the building materially affecting Tenant(s) use of the premise, shall
      be
      taken by eminent domain, this lease shall terminate on the date when title
      vests
      pursuant to such taking. The rent and any additional rent, shall be apportioned
      as of the termination date and any rent paid for any period beyond that date
      shall be repaid to Tenant. Tenant shall not be entitled to any part of the
      award
      for such taking or any payment in lieu thereof, but Tenant may file a claim
      for
      any taking of fixtures, improvements owned by Tenant and for moving expenses.
      

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    14) Destruction
      of Premises: In the event of a partial destruction of the premises during the
      term hereof, from any cause, Landlord shall forthwith repair the same, provided
      that such repairs can be made within sixty (60) days under existing governmental
      laws and regulations, but such partial destruction shall not terminate this
      lease, except that Tenant shall be entitled to a proportionate reduction of
      rent
      while such repairs are being made, based upon the extent to which the making
      of
      such repairs shall interfere with the business of Tenant on the premises. If
      such repairs cannot be made within said sixty (60) days, Landlord, at
      Landlord(s) option, may make the same within a reasonable time, this lease
      continuing in effect with the rent proportionately abated as aforesaid and
      in
      the event that Landlord shall not elect to make such repairs which cannot be
      made within sixty (60) days, this lease may be terminated at the option of
      either party. In the event that the building in which the demised premises
      may
      be situated is destroyed to an extent of not less than one-third of the
      replacement costs thereof, Landlord may elect to terminate this lease whether
      the demised premises be injured or not. A total destruction of the building
      in
      which the premises may be situated shall terminate this lease. 

    

    15) Landlord(s)
      Remedies on Default: 

    

    a) Default:
      Subject to Section 3(c), if Tenant defaults in the payment of rent or any
      additional rent or defaults in the performance of any of the other covenants
      or
      conditions hereof, Landlord may give Tenant notice of such default and if Tenant
      does not cure any such default within ten (10) business days, after the giving
      of such notice (or if such other default is of such nature that it cannot be
      completely cured within such period, if Tenant does not commence such curing
      within such ten (10) days and thereafter proceed with reasonable diligence
      and
      in good faith to cure such default), then Landlord may terminate this lease
      on
      not less than ten (10) business days notice to Tenant. On the date specified
      in
      such notice the term of this lease shall terminate and Tenant shall then quit
      and surrender the premises to Landlord, but Tenant shall remain liable as
      hereinafter provided. If this lease shall have been so terminated by Landlord,
      Landlord may at any time thereafter resume possession of the premises by any
      lawful means and remove Tenant or other occupants and their effects. No failure
      to enforce any term shall be deemed a waiver.

    

    b) Limitation
      of Redress: Landlord hereby agrees that under no circumstance whatsoever shall
      Tenant’s default of this Lease (including, without limitation, a default in
      payment) give Landlord any right, interest, ownership or access to Tenant’s
      intellectual property rights including, without limitation, Tenant’s software,
      domain names or trademarks. Further, Landlord shall have no right, interest,
      ownership or access to any media that contains any of Tenant’s intellectual
      property rights including, without limitation, Tenant’s files, servers, and
      computers. Tenant shall have the right to access and remove any such media
      from
      the Leased Premises within two (2) days of requesting Landlord. Landlord agrees
      that, in the event that it fails to allow Tenant to access and remove such
      media
      within the two (2) days, then, in addition to any remedies at law Tenant may
      have, Tenant, shall be entitled to obtain equitable relief in the form of
      specific performance, a temporary restraining order, a temporary or permanent
      injunction or any other equitable remedy that may be available.

    

    16) Attorney(s)
      Fees: In case suit should be brought for recovery of the premises or for any
      sum
      due hereunder or because of any act which may arise out of the possession of
      the
      premises, by either party, the prevailing party shall be entitled to all costs
      incurred in connection with such action, including a reasonable attorney(s)
      fee.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    17) Notices:
      Any notice which either party may or is required to give, shall be given by
      mailing the same, postage prepaid, to Tenant at the Leased Premises or Landlord
      as follows -- Trackside Brothers LLC, 313 N.E. 3rd Street, Delray Beach, FL
      33444 -- or at such other places as may be designated by the parties from time
      to time.

    

    18) Heirs,
      Assigns, Successors: This lease is binding upon and inures to the benefit of
      the
      heirs, assigns and successors in interest to the parties. 

    

    19) Option
      to
      Terminate/Renew: 

    

    a) Termination:
      Provided that Tenant is not in default in the performance of this lease, Tenant
      shall have the option to terminate the lease at any time by providing thirty
      (30) days prior written notice. In such event, and as a condition for
      termination, unless otherwise agreed upon by the parties in writing, Tenant
      must
      be current in all payments provided under Section 3 above (including, without
      limitation, payment of any deferred/accrued amounts identified in Section 3(c))
      and Tenant must pay to Landlord a termination fee in an amount equal to one
      month of Base Rent and Tenant’s pro-rata share of Operating Expenses. The Lease
      shall then terminate and there shall be no recalculation of actual Operating
      Expenses and no payment from Tenant to Landlord for underpayment nor
      reimbursement from Landlord to Tenant for overpayment.

    

    b) Renewal:
      Provided that Tenant is not in default in the performance of this lease, Tenant
      shall have the option to renew the lease for an additional term of twelve (12)
      months commencing at the expiration of the initial lease term. All of the terms
      and conditions of the lease shall apply during the renewal term except that
      the
      Base Rent payable monthly shall be increased to an amount equal to $3,900.
      Landlord shall recalculate the Operating Expenses for 2008 based on the
      Operating Expenses for 2007 and Tenant’s pro-rata estimated share of Operating
      Expenses shall be recalculated and paid all in accordance with Section 3(b).
      The
      option shall be exercised by written notice given to Landlord not less than
      thirty (30) days prior to the expiration of the initial lease term. If notice
      is
      not given in the manner provided herein within the time specified, this option
      shall expire. 

    

    20) Subordination:
      This lease is and shall be subordinated to all existing and future liens and
      encumbrances against the property.

    

    21) Additional
      No Waiver: No failure by Landlord to insist upon the performance of any of
      the
      terms of this Lease or to exercise any right or remedy consequent upon a breach
      thereof, and no acceptance by Landlord of full or partial rent from Tenant
      or
      any third party during the continuance of any such breach, shall constitute
      a
      waiver of any such breach or of any of the terms of this Lease.

    

    22) Captions
      and Interpretation: The captions of the Articles and Sections of this Lease
      are
      to assist the parties in reading this Lease and are not a part of the terms
      or
      provisions of this Lease. 

    

    23) Relationship
      of Parties: This Lease does not create the relationship of principal and agent,
      or of partnership, venture, or of any association or relationship between
      Landlord and Tenant, the sole relationship between Landlord and Tenant being
      that of landlord and tenant. 

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    24) Severability:
      If any covenant, condition, provision, term or agreement of this Lease shall,
      to
      any extent, be held invalid or unenforceable, the remaining covenants,
      conditions, provisions, terms and agreements of this Lease shall not be affected
      thereby, but each covenant, condition, provision, term or agreement of this
      Lease shall be valid and in force to the extent permitted by Law.

    

    25) Survival:
      All obligations accruing prior to expiration of the Term shall survive the
      expiration or other termination of this Lease.

    

    26) Governing
      Law; Venue: This Lease and the rights and obligations of the parties hereto
      shall be interpreted, construed, and enforced in accordance with the laws of
      the
      State of Florida without regard to principles of conflicts of law. Venue of
      all
      proceedings in connection therewith shall be in Palm Beach County, Florida,
      and
      each party hereby waives whatever their respective rights may have been in
      the
      selection of venue.

    

    27) 
      Entire
      Lease: The foregoing constitutes the entire agreement between the parties and
      may be modified only by a writing signed by both parties. 

    

    IN
      WITNESS WHEREOF, Landlord and Tenant have executed this Lease in multiple
      original counterparts as of the 8th day of January 2007. 

     

    
      	LANDLORD:	 	 	TENANT:
	
               

              TRACKSIDE BROTHERS LLC, 

              a Florida limited liability company

            	 	 	
               

              MEDSTRONG INTERNATIONAL

              CORPORATION,
                a Delaware corporation 

            
	 	 	 	 
	By:  /s/
              Mark Minkin	 	 	By: 
/s/
              Stephen Bartkiw
	
              
                

              

               

              Print Name: 

            	 	 	
              
                

              

               

              Print Name: 

            
	
              
                
 

            	 	 	
              
                
 

            
	
              Title:   

            	 	 	Title:

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