Document:

<PAGE>

Exhibit 10.2

THIS NOTE HAS NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED.
IT MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED OR HYPOTHECATED IN THE ABSENCE OF
AN EFFECTIVE REGISTRATION STATEMENT AS TO THE SECURITIES UNDER SAID ACT OR AN
OPINION OF COUNSEL SATISFACTORY TO THE CORPORATION THAT SUCH REGISTRATION IS NOT
REQUIRED.

                                 NUMOBILE, INC.

                                 PROMISSORY NOTE

$5,000,000.00                                                September 9, 2009
                                                          Louisville, Kentucky

         FOR VALUE RECEIVED, NUMOBILE, INC., a Nevada corporation (the
"BORROWER") promises to pay to Aubrey C. Brown ("LENDER"), or his registered
assigns, subject to the terms and conditions set forth herein, in lawful money
of the United States of America the principal sum of Five Million and 0/100
Dollars ($5,000,000.00), or such lesser amount as shall equal the outstanding
principal amount hereof, together with interest (a) from the date of this Note
(with respect to the Initial Principal Amount) (as defined below) on the unpaid
Initial Principal Amount balance, and (b) subject to the satisfaction of the
Final Principal Amount Conditions (as defined below), from April 1, 2011 (with
respect to the Final Principal Amount) (as defined below) on the unpaid Final
Principal Amount balance, at a rate equal to eight percent (8%) per annum,
computed on the basis of the actual number of days elapsed and a year of 365
days. One Million and 0/100 Dollars ($1,000,000) (the "INITIAL PRINCIPAL
AMOUNT") (less any principal payments with respect to the Initial Principal
Amount previously paid in accordance with the terms hereof), of the principal
sum under this Note, together with any then unpaid and accrued interest on the
Initial Principal Amount, and other amounts payable hereunder with respect to
the Initial Principal Amount, shall be due and payable on the earlier of (i)
September 9, 2010 (the "INITIAL MATURITY DATE"), or (ii) when, upon or after the
occurrence of an Event of Default (as defined below) such amounts are declared
due and payable by Lender or made automatically due and payable in accordance
with the terms hereof. Subject to the satisfaction of the Final Principal Amount
Conditions, Four Million and 0/100 Dollars ($4,000,000) (the "FINAL PRINCIPAL
AMOUNT") (less any principal payments with respect to the Final Principal Amount
previously paid in accordance with the terms hereof), of the principal sum under
this Note, together with any then unpaid and accrued interest on the Final
Principal Amount, and other amounts payable hereunder with respect to the Final
Principal Amount, shall be due and payable on the earlier of (i) September 9,
2014 (the "FINAL MATURITY DATE"), or (ii) when, upon or after the occurrence of
an Event of Default (as defined below) such amounts are declared due and payable
by Lender or made automatically due and payable in accordance with the terms
hereof. If the Final Principal Amount Conditions are not satisfied, payment of
the Initial Principal Amount, together with interest and other payments due on

<PAGE>

the Initial Principal Amount, shall be deemed payment in full of this Note and,
subject to such payment, this Note shall be deemed paid in full and cancelled on
April 1, 2011.

         The following is a statement of the rights of Lender and the conditions
to which this Note is subject, and to which Lender, by the acceptance of this
Note, agrees:

         1. DEFINITIONS. As used in this Note, the following capitalized terms
have the following meanings:

                  (a) the "BORROWER" includes the corporation initially
executing this Note and any Person which shall succeed to or assume the
obligations of the Borrower under this Note.

                  (b) "EVENT OF DEFAULT" has the meaning given in SECTION 3
hereof.

                  (c) "FINAL PRINCIPAL AMOUNT CONDITIONS" means the following
conditions, the satisfaction of which shall be a condition to the obligations of
the Borrower to pay the Final Principal Amount, any interest thereon, and any
other payments with respect thereto: Prior to April 1, 2011, Enhance Network
Communication, Inc. shall enter into a contract with respect to its proprietary
technology that contemplates the generation of at least $20,000,000 in revenue
and $8,000,000 or gross margin.

                  (d) "LENDER" shall mean the Person specified in the
introductory paragraph of this Note or any Person who shall at the time be the
registered holder of this Note.

                  (e) "OBLIGATIONS" shall mean and include all principal,
interest and obligations, howsoever arising, owed by the Borrower to Lender, now
existing or hereafter arising under or pursuant to the terms of this Note,
provided that, no obligations shall arise under this Note with respect to
principal, interest, or other payments with respect to the Final Principal
Amount unless the Final Principal Amount Conditions shall be met, and provided
further that, no obligations shall arise under this Note with respect to
principal, interest or other payments with respect to the Final Principal Amount
prior to April 1, 2011.

                  (f) "PERSON" shall mean and include an individual, a
partnership, a corporation (including a business trust), a joint stock company,
a limited liability company, an unincorporated association, a joint venture or
other entity or a governmental authority.

                  (g) "SECURITIES ACT" shall mean the Securities Act of 1933, as
amended.

                  (h) "TRANSACTION DOCUMENTS" shall mean this Note.

         2. PREPAYMENT. Upon ten (10) days prior written notice to Lender, the
Borrower may prepay this Note in whole or in part; provided that any such
prepayment will be applied first to the payment of expenses due under this Note,
second to interest accrued on this Note and third, if the amount of prepayment
exceeds the amount of all such expenses and accrued interest, to the payment of
principal of this Note.

                                       -2-
<PAGE>

         3. EVENTS OF DEFAULT. The occurrence of any of the following shall
constitute an "EVENT OF DEFAULT" under this Note and the other Transaction
Documents:

                  (a) FAILURE TO PAY. The Borrower shall fail to pay (i) when
due any principal or interest payment on the due date hereunder or (ii) any
other payment required under the terms of this Note on the date due and such
payment shall not have been made within five (5) days of the Borrower's receipt
of Lender's written notice to the Borrower of such failure to pay; or

                  (b) VOLUNTARY BANKRUPTCY OR INSOLVENCY PROCEEDINGS. The
Borrower shall (i) apply for or consent to the appointment of a receiver,
trustee, liquidator or custodian of itself or of all or a substantial part of
its property, (ii) be unable, or admit in writing its inability, to pay its
debts generally as they mature, (iii) make a general assignment for the benefit
of its or any of its creditors, (iv) be dissolved or liquidated, (v) become
insolvent (as such term may be defined or interpreted under any applicable
statute), (vi) commence a voluntary case or other proceeding seeking
liquidation, reorganization or other relief with respect to itself or its debts
under any bankruptcy, insolvency or other similar law now or hereafter in effect
or consent to any such relief or to the appointment of or taking possession of
its property by any official in an involuntary case or other proceeding
commenced against it, or (vii) take any action for the purpose of effecting any
of the foregoing; or

                  (c) INVOLUNTARY BANKRUPTCY OR INSOLVENCY PROCEEDINGS.
Proceedings for the appointment of a receiver, trustee, liquidator or custodian
of the Borrower or of all or a substantial part of the property thereof, or an
involuntary case or other proceedings seeking liquidation, reorganization or
other relief with respect to the Borrower or the debts thereof under any
bankruptcy, insolvency or other similar law now or hereafter in effect shall be
commenced and an order for relief entered or such proceeding shall not be
dismissed or discharged within 30 days of commencement.

         4. RIGHTS OF LENDER UPON DEFAULT. Upon the occurrence or existence of
any Event of Default (other than an Event of Default described in SECTIONS 3(B)
or 3(C)) and at any time thereafter during the continuance of such Event of
Default, Lender may, by written notice to the Borrower, declare all outstanding
Obligations payable by the Borrower hereunder to be immediately due and payable
without presentment, demand, protest or any other notice of any kind, all of
which are hereby expressly waived. Upon the occurrence or existence of any Event
of Default described in SECTIONS 3(B) and 3(C), immediately and without notice,
all outstanding Obligations payable by the Borrower hereunder shall
automatically become immediately due and payable, without presentment, demand,
protest or any other notice of any kind, all of which are hereby expressly
waived. In addition to the foregoing remedies, upon the occurrence or existence
of any Event of Default, Lender may exercise any other right power or remedy
granted to it by the Transaction Documents or otherwise permitted to it by law,
either by suit in equity or by action at law, or both.

         5. REPRESENTATIONS AND WARRANTIES.

                  (a) REPRESENTATIONS AND WARRANTIES OF THE BORROWER. The
Borrower hereby represents and warrants to the Lender:

                                      -3-
<PAGE>

                           (i) AUTHORITY. The execution, delivery and
performance by the Borrower of the Note and the consummation of the transactions
contemplated thereby (i) are within the power of the Borrower and (ii) have been
duly authorized by all necessary actions on the part of the Borrower.

                           (ii) ENFORCEABILITY. The Note has been duly executed
and delivered by the Borrower and constitutes a legal, valid and binding
obligation of the Borrower, enforceable against the Borrower in accordance with
its terms, except as limited by bankruptcy, insolvency or other laws of general
application relating to or affecting the enforcement of creditors' rights
generally and general principles of equity.

                           (iii) APPROVALS. No consent, approval, order or
authorization of, or registration, declaration or filing with, any governmental
authority or other Person (including, without limitation, the shareholders of
any Person) is required in connection with the execution and delivery of the
Note and the performance and consummation of the transactions contemplated
thereby, except for those consents which have been obtained.

                  (b) REPRESENTATIONS AND WARRANTIES OF THE LENDER. Lender
hereby represents and warrants to the Borrower:

                           (i) AUTHORITY. The purchase of the Note, and the
execution and delivery by the Lender of the Note (i) are within the power of the
Lender and (ii) have been duly authorized by all necessary actions on the part
of the Lender.

                           (ii) ENFORCEABILITY. The Note has been duly executed
and delivered by the Lender and constitutes a legal, valid and binding
obligation of the Borrower, enforceable against the Borrower in accordance with
its terms, except as limited by bankruptcy, insolvency or other laws of general
application relating to or affecting the enforcement of creditors' rights
generally and general principles of equity.

                           (iii) APPROVALS. No consent, approval, order or
authorization of, or registration, declaration or filing with, any governmental
authority or other Person (including, without limitation, the shareholders of
any Person) is required in connection with the purchase of the Note, and the
execution and delivery of the Note, except for those consents which have been
obtained.

                           (iv) SECURITIES LAW COMPLIANCE. Lender has been
advised that the Note has not been registered under the Securities Act, or any
state securities laws and, therefore, cannot be resold unless they are
registered under the Securities Act and applicable state securities laws or
unless an exemption from such registration requirements is available. Such
Lender is aware that the Borrower is under no obligation to effect any such
registration with respect to the Note or to file for or comply with any
exemption from registration. Such Lender has not been formed solely for the
purpose of making this investment and is purchasing the Note for its own account
for investment, not as a nominee or agent, and not with a view to, or for resale
in connection with, the distribution thereof. Lender has such knowledge and
experience in financial and business matters that such Lender is capable of
evaluating the merits and risks of such investment, is able to incur a complete

                                       -4-
<PAGE>

loss of such investment and is able to bear the economic risk of such investment
for an indefinite period of time. Lender is an accredited investor as such term
is defined in Rule 501 of Regulation D under the Securities Act. Lender is able
to bear the economic risk of the purchase of the Note.

         6. SUCCESSORS AND ASSIGNS. Subject to the restrictions on transfer
described in SECTIONS 9 and 10 below, the rights and obligations of the Borrower
and Lender shall be binding upon and benefit the successors, assigns, heirs,
administrators and transferees of the parties.

         7. WAIVER AND AMENDMENT. Any provision of this Note may be amended,
waived or modified upon the written consent of the Borrower and the Lender.

         8. TRANSFER OF THIS NOTE. With respect to any offer, sale or other
disposition of this Note, Lender will give written notice to the Borrower prior
thereto, describing briefly the manner thereof, together with a written opinion
of Lender's counsel, or other evidence if reasonably satisfactory to the
Borrower, to the effect that such offer, sale or other distribution may be
effected without registration or qualification (under any federal or state law
then in effect). Upon receiving such written notice and reasonably satisfactory
opinion, if so requested, or other evidence, the Borrower, as promptly as
practicable, shall notify Lender that Lender may sell or otherwise dispose of
this Note, all in accordance with the terms of the notice delivered to the
Borrower. If a determination has been made pursuant to this SECTION 9 that the
opinion of counsel for Lender, or other evidence, is not reasonably satisfactory
to the Borrower, the Borrower shall so notify Lender promptly after such
determination has been made. Each Note thus transferred shall bear a legend as
to the applicable restrictions on transferability in order to ensure compliance
with the Securities Act, unless in the opinion of counsel for the Borrower such
legend is not required in order to ensure compliance with the Securities Act.
The Borrower may issue stop transfer instructions to its transfer agent in
connection with such restrictions. Subject to the foregoing, transfers of this
Note shall be registered upon registration books maintained for such purpose by
or on behalf of the Borrower. Prior to presentation of this Note for
registration of transfer, the Borrower shall treat the registered holder hereof
as the owner and holder of this Note for the purpose of receiving all payments
of principal and interest hereon and for all other purposes whatsoever, whether
or not this Note shall be overdue and the Borrower shall not be affected by
notice to the contrary.

         9. ASSIGNMENT BY THE BORROWER. Neither this Note nor any of the rights,
interests or obligations hereunder may be assigned, by operation of law or
otherwise, in whole or in part, by the Borrower without the prior written
consent of the Holder.

         10. NOTICES. All notices, requests, demands, consents, instructions or
other communications required or permitted hereunder shall in writing and faxed,
mailed or delivered to each party at the respective addresses of the parties as
set forth on the signature page hereto, or at such other address or facsimile
number as such party shall have furnished to the other party in writing. All
such notices and communications will be deemed effectively given the earlier of
(i) when received, (ii) when delivered personally, (iii) one business day after
being delivered by facsimile (with receipt of appropriate confirmation), (iv)
one business day after being deposited with an overnight courier service of

                                       -5-
<PAGE>

recognized standing or (v) four days after being deposited in the U.S. mail,
first class with postage prepaid.

         11. USURY. In the event any interest is paid on this Note which is
deemed to be in excess of the then legal maximum rate, then that portion of the
interest payment representing an amount in excess of the then legal maximum rate
shall be deemed a payment of principal and applied against the principal of this
Note.

         12. WAIVERS. The Borrower hereby waives notice of default, presentment
or demand for payment, protest or notice of nonpayment or dishonor and all other
notices or demands relative to this instrument.

         13. GOVERNING LAW. This Note and all actions arising out of or in
connection with this Note shall be governed by and construed in accordance with
the laws of the State of Nevada, without regard to the conflicts of law
provisions of the State of Nevada, or of any other state.

                            [SIGNATURE PAGE FOLLOWS]

                                       -6-
<PAGE>

                        SIGNATURE PAGE TO PROMISSORY NOTE

         The Borrower has caused this Note to be issued and delivered, and the
Lender has caused this Note to be duly executed and delivered, as of the date
first written above.

                                       NUMOBILE, INC.

                                       By:       /s/ James Tilton
                                                 -------------------------------
                                       Name:     James Tilton
                                                 -------------------------------
                                       Title:    Chief Executive Officer
                                                 -------------------------------

                                       INITIAL ADDRESS FOR NOTICE:

                                                 2520 South Third Street #206
                                                 -------------------------------
                                                 Louisville, Kentucky 40208
                                                 -------------------------------
                                                 Fax: 502-636-2806
                                                 -------------------------------
                                                 Phone:   502-636-2807
                                                 -------------------------------
                                                 Attn:    President
                                                 -------------------------------

                    /s/ Aubrey C. Brown
                    ----------------------------------------------
                    Aubrey C. Brown

INITIAL ADDRESS FOR NOTICE:

         19925 Stevens Creek Blvd., Suite 100
         ---------------------------------------------------------
         Cupertino, CA 95014
         ---------------------------------------------------------
         Phone: 408-244-8500
         ---------------------------------------------------------
         Fax: 800-290-7064
         ---------------------------------------------------------

         ---------------------------------------------------------

                       SIGNATURE PAGE TO PROMISSORY NOTEex10_1.htm

THIS PROMISSORY NOTE HAS BEEN ACQUIRED FOR INVESTMENT PURPOSES ONLY AND NOT FOR DISTRIBUTION AND MAY BE TRANSFERRED OR OTHERWISE DISPOSED OF ONLY IN COMPLIANCE WITH THE SECURITIES ACT OF l933, AS AMENDED (THE “ACT”).

 

KINGSTONE COMPANIES, INC.

 

September _, 2009

 

PROMISSORY NOTE

 

Due July 10, 2011

 

KINGSTONE COMPANIES, INC., a Delaware corporation (the “Company”), for value received, hereby promises to pay to ____________________________________________ or order (the “Holder”) on July 10, 2011
(the “Maturity Date”) at the offices of the Company, 1158 Broadway, Hewlett, New York, the principal sum of __________________________________________________ ($___________) DOLLARS in such coin or currency of the United States of America as at the time of payment shall be legal tender for the payment of public and private debts and to pay interest on said principal sum at the rate
of twelve and five-eighths percent (12.625%) per annum through the Maturity Date.  Interest on the principal balance of this Promissory Note (“Note”) from the date hereof (the “Issue Date”) shall be payable on each January 10 and July 10 commencing on January 10, 2010.

 

1. Series of Notes.  This Note is one of a series of Promissory Notes, identical in form (the “Notes”),
issued on or about the date hereof, in the aggregate principal amount of $250,000.  All Notes in such series shall rank equally and ratably without preference or priority of any said Notes over any others thereof.

 

2. Registered Owner.  The Company may consider and treat the person in whose name this Note shall be
registered as the absolute owner thereof for all purposes whatsoever (whether or not this Note shall be overdue) and the Company shall not be affected by any notice to the contrary.  Subject to the provisions hereof, the registered owner of this Note shall have the right to transfer it by assignment and the transferee thereof, upon its registration as owner of this Note, shall become vested with all the powers and rights of the transferor.  Registration of any new owner shall take place upon
presentation of this Note to the Company at its offices together with the Note Assignment Form attached hereto duly executed.  In case of transfers by operation of law, the transferee shall notify the Company of such transfer and of its address, and shall submit appropriate evidence regarding the transfer so that this Note may be registered in the name of the transferee.  This Note is transferable only on the books of the Company by the Holder on the surrender hereof, duly endorsed. Communications
sent to any registered owner shall be effective as against all holders or transferees of this Note not registered at the time of sending the communication.

 

3. Consent Required.  Except with the prior written consent of the Holder, the Company shall not grant a security interest
in any of its assets to secure the repayment of any indebtedness incurred by it for borrowed funds.

 

 

 

 

4. Redemption.

 

4.1 Redemption Right. The Holder, by its acceptance of this Note, hereby acknowledges that, at any time, and from time to time, prior
to the Maturity Date, the Company may, at its option, by written notice given to the Holder, elect to redeem and prepay all or any portion of the outstanding principal indebtedness evidenced by this Note, without premium or penalty.  Any such notice of the Company’s election to redeem and prepay as provided for hereinabove shall indicate the principal amount to be redeemed and prepaid (the “Redemption Amount”) and shall be given not less than thirty (30) days prior to the date fixed
in such notice as the date for the redemption of this Note (the “Redemption Date”).

 

4.2 Interest.  In the event the Company so elects to redeem and prepay this Note, in whole or in part,
pursuant to Section 4.1 hereof, it shall pay to the Holder, in addition to the principal amount being prepaid, accrued interest thereon through the Redemption Date; provided, however, that, if the Redemption Date is prior to the six (6) month anniversary of the Issue Date, additional interest shall be payable hereunder such that the Holder receives an amount of interest on the Redemption Date equal to six (6) months interest on the Redemption Amount less any interest theretofore paid thereon.

 

4.3 Obligations.  On the Redemption Date, this Note shall be due and payable to the extent provided
for in Sections 4.1 and 4.2 hereof and, if the remaining balance of the principal amount of this Note is payable on the Redemption Date, the Holder shall tender to the  Company this Note for cancellation.  Effective with the Redemption Date, with respect to the Redemption Amount, interest will cease to accrue, and the only right of the Holder shall be to receive the amount payable upon redemption.

 

5. Events of Default.  If the Company shall (i) fail to make any payment due hereunder and such failure
shall continue unremedied for a period of fifteen (15) days following receipt of written notice thereof from the Holder; (ii) violate the provisions of Section 3 hereof; (iii) admit in writing its inability to pay its debts generally as they mature; (iv) make a general assignment for the benefit of creditors; (v) be adjudicated a bankrupt or insolvent; (vi) file a voluntary petition in bankruptcy or a petition or an answer seeking an arrangement with creditors; (vii) take advantage of any bankruptcy, insolvency
or readjustment of debt law or statute or file an answer admitting the material allegations of a petition filed against it in any proceeding under any such law; (viii) apply for or consent to the appointment of a receiver, trustee or liquidator for all or substantially all of its assets; or (ix) have an involuntary case commenced against it under the Federal bankruptcy laws, which case is not dismissed or stayed within sixty (60) days (each an “Event of Default”), then, at any time thereafter and
unless such Event of Default shall have been cured or shall have been waived in writing by the Holder, the Holder may, by written notice to the Company, declare the entire unpaid principal amount of this Note then outstanding, together with accrued interest thereon, to be forthwith due and payable, whereupon the same shall become forthwith due and payable.

 

6. Investment Intent. The Holder, by its acceptance hereof, hereby represents and warrants that this Note is being acquired for investment
purposes only and without a view to the distribution thereof, and may be transferred only in compliance with the Act.

 

 

 

 

7. Transfer to Comply with the Securities Act of l933.  This Note may not be sold or otherwise disposed of except as follows:
(a) to a person or entity to whom this Note may legally be transferred without registration and without the delivery of a current prospectus under the Act with respect thereto or (b) to any person or entity upon delivery of a prospectus then meeting the require­ments of the Act relating to such securities and the offering thereof for such sale or disposition, and thereafter to all successive assignees.

 

8. Costs of Collection.  In  the event the Company shall default in the payment of this Note
when due, then the Company shall pay, in addition to unpaid principal and interest, all the costs and expenses incurred in effecting collection hereunder, including reasonable attorneys’ fees.

 

9. Applicable Law.  This Note is issued under and shall for all purposes be governed by and construed in accordance with
the laws of the State of New York, excluding choice of law rules thereof.

 

10. Notices.  Any notice required or permitted to be given pursuant to this Note shall be deemed to
have been duly given when delivered by hand or sent by certified or registered mail, return receipt requested and postage prepaid, overnight mail or telecopier as follows:

 

If to the Holder:

 

_______________________

_______________________

_______________________

 

If to the Company:

1158 Broadway

Hewlett, NY 11557

Attn:  Chief Financial Officer

Facsimile No.:  (516) 295-7216

With a copy to

Certilman Balin Adler & Hyman, LLP

90 Merrick Avenue

East Meadow, NY 11554

Attn: Fred Skolnik, Esq.

Facsimile No.: (516) 296-7111

or at such other address as the Holder or the Company shall designate by notice to the other given in accordance with this Section 10.

 

11. Miscellaneous.  This Note evidences the entire obligation of the Company with respect to the repayment
of the principal amount hereof and the other matters provided for herein.  No provision of this Note may be modified except by an instrument in writing signed by  the Company and the Holder.  Payment of interest due under this Note prior to the Maturity Date or Redemption Date, as the case may be, shall be made to the registered Holder of this Note.  Payment of principal and interest due upon redemption or maturity shall be made to the registered Holder of this Note on
or after the Redemption Date or Maturity Date, as the case may be, contemporaneous with and upon presentation of this Note for payment.  No interest shall be due on this Note for such period of time that may elapse between the Redemption Date or Maturity Date, as the case may be, and its presentation for payment.  Notwithstanding the foregoing, it shall not be necessary for the Holder to present this Note for payment in the event of a partial redemption of this Note.

 

 [Remainder of page intentionally left blank.  Signature page follows.]

 

 

 

  

  

  

IN WITNESS WHEREOF, the Company has caused this Note to be signed on its behalf, in its corporate name, by its duly authorized officer, all as of the day and year first above written.

 

KINGSTONE COMPANIES, INC.

By:___________________________

 

  

  

  

KINGSTONE COMPANIES, INC.

PROMISSORY NOTE

DUE JULY 10, 2011

NOTE ASSIGNMENT FORM

FOR VALUE RECEIVED

The undersigned _____________________________ (please print or typewrite name of assignor) hereby sells, assigns and transfers unto ______________________________________________________

(please print or typewrite name, address and social security or taxpayer identification number, if any, of assignee)  the within Promissory Note of Kingstone Companies, Inc., dated _____________, 2009, in the original principal amount of $____________ and hereby authorizes the Company  to transfer this Note on its books.

 

	
If the Holder is an individual:
	
If the Holder is not an individual:

	
 

___________________________

Name(s) of Holder
	
 

_________________________________

Name of Holder

	  	  
	
 

___________________________

Signature of Holder
	
 

By: ______________________________                                                     

      Signature of Authorized Representative

	
 

___________________________

Signature, if jointly held
	
 

_________________________________

Name and Title of Authorized Representative

	
 

___________________________

Date
	
 

_________________________________

Date

	  	  
	
__________________________

(Signature(s) guaranteed)

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