Document:

Unassociated Document

    10.1 Note
      with
      Wibeke Albrecht for a total of $52,862, dated August 9, 2006

    

    PROMISSORY
      NOTE AND AGREEMENT

    

    For
      value
      received, Isdera, North America, Inc., a New York Corporation, also referred
      to
      as Maker, promises to pay to the order of Wibeke Albrecht, her successors and
      assigns, hereafter referred to as Holder, the sum of FIFTY TWO THOUSAND EIGHT
      HUNDRED SIXTY-TWO DOLLARS and no cents ($52,862). This note carries an interest
      rate of 5% per year and is payable on demand.

    

    
      	1.  	
              Each
                maker, surety, guarantor and endorser of this Note waives all notices
                of
                dishonor, demands for payment, presentments for payment, notices
                of
                intention to accelerate maturity, protests an notices of protest
                with
                respect to this Note and each, every and all installments hereunder
                and
                agrees to all renewals, extensions or partial payments hereof, with
                or
                without notice and before or after
                maturity.

            

    

    

    
      	2.  	
              The
                unpaid principal balance of their Note may be prepaid at any time
                in
                whole, or from time to time in part, without premium or penalty,
                provided
                that all accrued interest on the principal amount so prepaid is likewise
                paid.

            

    

    

    
      	3.  	
              If
                this Note is placed in the hand of an attorney for collection or
                collected
                through probate, bankruptcy or other judicial proceedings, the holder
                hereof shall be entities to reasonable attorney’s fees for collection. The
                laws of the State of New York shall apply to this
                Note.

            

    

    

    
      	4.  	
              This
                Note is freely assignable.

            

    

    

    
      	 	 	 	 
	/s/ 	 	 	
            
	
              

            	 	 	
            
	
              Ruediger
                Albrecht

              President

              Isdera,
                North America, Inc.

            	 	 	
            

    
      
        
        

      

      
        33THESE
      SECURITIES HAVE NOT BEEN REGISTERED FOR OFFER OR SALE UNDER THE SECURITIES
      ACT
      OF 1933 OR ANY STATE SECURITIES LAWS. THEY MAY NOT BE SOLD OR OFFERED FOR SALE
      EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER SAID ACT AND ANY
      APPLICABLE STATE SECURITIES LAW OR AN APPLICABLE EXEMPTION FROM SUCH
      REGISTRATION REQUIREMENTS.

     

    CELSIA
      TECHNOLOGIES, INC. 

     

    SECURED
      CONVERTIBLE PROMISSORY NOTE

     

    
      	$_____________________	
              Dated: _____________

            
	(Original Principal Amount) 	
               (“Issuance
                Date”)

            

    

         

    FOR
      VALUE
      RECEIVED, CELSIA TECHNOLOGIES, INC., a Nevada corporation (the “Company”),
      hereby promises to pay to___________________(the
      “Payee”),
      or
      their registered assigns, the principal amount of___________________($________)
      together with interest thereon calculated from the date hereof in accordance
      with the provisions of this Secured Convertible Promissory Note (as amended,
      modified and supplemented from time to time, this “Convertible
      Note”
and
      together with any other Convertible Notes issued in the Convertible Note
      Issuance (as defined below) or upon transfer or exchange, the “Convertible
      Notes”).
      Capitalized terms not defined in this Convertible Note shall have the meaning
      ascribed to them in the Securities Purchase Agreement.

     

    Certain
      capitalized terms are defined in Section
      8
      hereof.

     

    1.  Payment
      of Interest.
      Interest shall accrue from the Issuance Date at a rate equal to ten percent
      (10%) per annum (the “Interest
      Rate”)
      on the
      unpaid principal amount of this Convertible Note and shall be payable on the
      Maturity Date; provided
      that
      so long
      as any Event of Default has occurred and is continuing, interest shall be deemed
      to accrue, to the extent permitted by law, at the rate of eighteen percent
      (18%)
      per annum retroactive to the date of this Convertible Note on the unpaid
      principal amount of this Convertible Note outstanding from time to time through
      the date on which such Event of Default ceases to exist. Interest shall be
      computed on the basis of the actual number of days elapsed and a 360-day
      year.

     

    2.  Maturity
      Date.
      The
      entire principal amount of this Convertible Note and all accrued but unpaid
      interest thereon shall be due and payable in full in cash in immediately
      available funds on the June 20, 2007 (such date, the “Maturity
      Date”).
      Any
      overdue principal and overdue interest together with any interest thereon,
      shall
      be due and payable upon demand.

     

    3.  Conversion.
      

     

    (i)  Notwithstanding
      the above, in the event a Qualified Debenture Financing is consummated, the
      principal amount of this Convertible Note plus accrued and unpaid interest
      thereon shall automatically be converted into Debentures issued by the Company
      in a Qualified Debenture Financing, as further described below; provided,
      however, if an Event of Default (as defined herein) shall have occurred prior
      to
      the consummation of a Qualified Debenture Financing, no such conversion shall
      occur and this Convertible Note shall remain outstanding in accordance with
      the
      terms hereof; provided further, that nothing in this proviso shall limit the
      ability of the holder of this Convertible Note from participating at the
      holder’s sole election in the Qualified Debenture Financing on the terms herein
      stated or on terms otherwise agreeable to such holder and the Company. The
      Company shall give Payee not less than five (5) days prior written notice of
      the
      closing of any Qualified Debenture Financing.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    (ii)  Upon
      any
      automatic conversion of this Convertible Note into a Debenture pursuant to
      Section 3(i), the principal amount of such Debenture that shall be issuable
      to the Payee shall equal the principal amount plus accrued and unpaid interest
      thereon of this Convertible Note multiplied by one hundred ten percent (110%)
      (rounded to the nearest whole dollar). The Debenture to be issued upon any
      such
      conversion shall have the same rights, preferences and privileges as the
      Debenture issued in the Qualified Debenture Financing. The Payee, upon making
      such conversion, shall be entitled to all the benefits of any agreements entered
      into among the Company and the holders of the Debenture. If the Debenture sold
      in the Qualified Debenture Financing are sold as units including warrants or
      other securities, the Payee upon conversion of this Convertible Note shall
      receive all the securities comprising such units; provided, however, that if
      warrants to purchase shares of Company common stock are issued as part of such
      units, the Payee shall receive additional warrants exercisable for a number
      of
      shares of Company common stock equal to thirty percent (30%) of the number
      of
      shares of common stock into which the Debenture issued to the Payee could be
      converted into as of the consummation of the Qualified Debenture Financing;
      provided further, that if a Qualified Debenture Financing shall not have
      occurred by the four (4) week anniversary of the Issuance Date, such thirty
      percent (30%) amount shall be increased to fifty percent (50%), with such
      additional warrants having the same terms as the warrants issued pursuant to
      the
      Qualified Debenture Financing.

     

    (iii)  Except
      as
      otherwise expressly provided herein, the conversion of this Convertible Note
      shall be deemed to have been effected on the date of the Qualified Debenture
      Financing once this Convertible Note has been surrendered for conversion at
      the
      principal office of the Company. At such time as such conversion has been
      effected, the rights of the holder of this Convertible Note as the holder of
      such note shall cease and the Person or Persons in whose name or names any
      Debenture are to be issued upon such conversion shall be deemed to have become
      the holder or holders of record of the shares of such Debentures represented
      thereby.

     

    (iv)  As
      soon
      as possible after the conversion of this Convertible Note has been effected
      (but
      in any event within three (3) Business Days), the Company shall deliver to
      the
      converting holder the Debenture issuable by reason of such conversion in the
      name of such converting holder.

     

    (v)  The
      Company shall not close its books against the transfer of Debenture issued
      or
      issuable upon conversion of this Convertible Note in any manner which interferes
      with the timely conversion of this Convertible Note. The Company shall assist
      and cooperate with any holder of this Convertible Note required to make any
      governmental filings or obtain any governmental approval prior to or in
      connection with the conversion of this Convertible Note (including, without
      limitation, making any filings required to be made by the Company).

     

    
      
        
        

      

      
        2

        
          

        

      

      
        
        

      

    

     

    4.  Seniority.
      The
      obligations of the Company to make payments of principal and interest hereunder
      shall rank senior to all other debt of the Company (excluding trade payables
      incurred in the ordinary course of business), whether now or hereinafter
      existing.

     

    5.  Method
      of Payments.

     

    (i)  Payment.
      The
      Company will pay all sums for principal and interest becoming due on this
      Convertible Note not later than 1:00 p.m. New York time, on the date such
      payment is due, in immediately available funds, in accordance with the payment
      instructions that the Payee shall designate in writing, without the presentation
      or surrender of such Convertible Note or the making of any notation thereon.
      Any
      payment made after 1:00 p.m. New York time, on a Business Day will be deemed
      made on the next following Business Day. If the due date of any payment in
      respect of this Convertible Note would otherwise fall on a day that is not
      a
      Business Day, such due date shall be extended to the next succeeding Business
      Day, and interest shall be payable on any principal so extended for the period
      of such extension. All amounts payable under this Convertible Note shall be
      paid
      free and clear of, and without reduction by reason of, any deduction, set-off
      or
      counterclaim. The Company will afford the benefits of this Section to the Payee
      and to each other Person holding this Convertible Note. The
      Company shall have no liability to any holder of Convertible Notes for failure
      to make any payment due to such holder due to such holder’s failure to provide
      payment instructions to the Company.

     

    (ii)  Transfer
      and Exchange.
      Subject
      to Section 17, upon surrender of any Convertible Note for registration of
      transfer or for exchange to the Company at its principal office, the Company
      at
      its sole expense will execute and deliver in exchange therefore a new
      Convertible Note or Convertible Notes, as the case may be, as requested by
      the
      holder or transferee, which aggregate the unpaid principal amount of such
      Convertible Note, registered as such holder or transferee may request, dated
      so
      that there will be no loss of interest on the Convertible Note and otherwise
      of
      like tenor.
      The
      issuance of new Convertible Notes shall be made without charge to the holder(s)
      of the surrendered Convertible Note for any issuance tax in respect thereof
      or
      other cost incurred by the Company in connection with such issuance, provided
      that each Convertible Noteholder shall pay any transfer taxes associated
      therewith. The Company shall be entitled to regard the registered holder of
      this
      Convertible Note as the holder of the Convertible Note so registered for all
      purposes until the Company or its agent, as applicable, is required to record
      a
      transfer of this Convertible Note on its register.

     

    (iii)  Replacement.
      Upon
      receipt of evidence reasonably satisfactory to the Company of the loss, theft,
      destruction or mutilation of any Convertible Note and, in the case of any such
      loss, theft or destruction of any Convertible Note, upon receipt of an indemnity
      reasonably satisfactory to the Company or, in the case of any such mutilation,
      upon the surrender and cancellation of such Convertible Note, the Company,
      at
      its expense, will execute and deliver, in lieu thereof, a new Convertible Note
      of like tenor and dated the date of such lost, stolen, destroyed or mutilated
      Convertible Note.

     

    
      
        
        

      

      
        3

        
          

        

      

      
        
        

      

    

     

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

     

    (i)  Incurrence
      of Debt.
      The
      Company shall not incur any debt other than the Convertible Notes, except
      (i) as consented to by the Required Majority (as defined herein),
      (ii) trade payables incurred in the ordinary course of business or
      (iii) a Qualified Debenture Financing.

     

    (ii)  Notice
      of Qualified Debenture Financing.
      At
      least five (5) days prior to the closing of any Qualified Debenture Financing,
      the Company shall provide Payee with written notice of such projected closing
      date, specifying the terms of the transaction and the proposed price per share
      of Debentures to be paid in such Qualified Debenture Financing. The Company
      shall
      promptly provide telephonic or electronic notice to Payee of any adjournments
      or
      rescheduling of such projected closing date.

     

    (iii)  Convertible
      Notes.
      All
      Convertible Notes shall be on the same terms and shall be in substantially
      the
      same form. All payments to the holder of any Convertible Note shall be made
      to
      all holders of Convertible Notes, pro rata, based on the aggregate principal
      amount plus accrued but unpaid interest outstanding on such Convertible Notes
      at
      such time.

     

    7.  Events
      of Default.
      If any
      of the following events (each, an “Event
      of Default”)
      takes
      place before the Maturity Date, the Required Majority at its option may declare
      all principal and accrued and unpaid interest thereon and all other amounts
      payable under this Convertible Note (including, without limitation, the amounts
      described in Section 9) immediately due and payable; provided,
      however,
      that
      this Convertible Note shall automatically become due and payable without any
      declaration in the case of an Event of Default specified in clause (ii), (iii),
      (v), (vi), (vii), (viii), (ix) or (xi) below:

     

    
      	(i)  	
              Company
                fails to make payment of the full amount due under this Convertible
                Note
                on a demand following the Maturity Date;
                or

            

    

     

    
      	(ii)  	
              A
                receiver, liquidator or trustee of Company or any substantial part
                of
                Company’s assets or properties is appointed by a court order;
                or

            

    

     

    
      	(iii)  	
              Company
                is adjudicated bankrupt or insolvent;
                or

            

    

     

    
      	(iv)  	
              Any
                of Company’s property is sequestered by or in consequence of a court order
                and such order remains in effect for more than 30 days;
                or

            

    

     

    
      	(v)  	
              Company
                files a petition in voluntary bankruptcy or requests reorganization
                under
                any provision of any bankruptcy, reorganization or insolvency law
                or
                consents to the filing of any petition against it under such law,
                or

            

    

     

    
      	(vi)  	
              Any
                petition against Company is filed under bankruptcy, receivership
                or
                insolvency law and such petition is not vacated within 30 days;
                or

            

    

     

    
      	(vii)  	
              Company
                makes a formal or informal general assignment for the benefit of
                its
                creditors, or admits in writing its inability to pay debts generally
                when
                they become due, or consents to the appointment of a receiver or
                liquidator of Company or of all or any part of its property;
                or

            

    

     

    
      
        
        

      

      
        4

        
          

        

      

      
        
        

      

    

     

    
      	(viii)  	
              An
                attachment or execution is levied against any substantial part of
                Company’s assets that is not released within 30 days;
                or

            

    

     

    
      	(ix)  	
              Company
                dissolves, liquidates, or transfers any major portion of its assets
                other
                than in the ordinary course of business;
                or

            

    

     

    
      	(x)  	
              Company
                breaches any covenant or agreement on its part contained in this
                Convertible Note or the Security Agreement, which breach is not cured
                within 15 days; or

            

    

     

    
      	(xi)  	
              Any
                material inaccuracy or untruthfulness of any representation or warranty
                of
                the Company set forth in this Convertible Note or the Security
                Agreement.

            

    

     

    8.  Definitions.

     

    “Agent”
means
      Axiom Capital Management, Inc., which has been appointed as the Agent for the
      holders of the Convertible Notes (including the Payee) pursuant to the Security
      Agreement. 

     

    “Business
      Day”
means
      a
      day (other than a Saturday or Sunday) on which banks generally are open in
      New
      York, New York for the conduct of substantially all of their
      activities.

     

    “Convertible
      Noteholder”
with
      respect to any Convertible Note, means at any time each Person then the record
      owner hereof and “Convertible
      Noteholders”
means
      all of such Convertible Noteholders collectively.

     

    “Convertible
      Note Issuance”
shall
      mean the Secured Convertible Promissory Notes due on the Maturity Date issued
      by
      the Company to the Payee and other Convertible Noteholders (each in the form
      of
      this Convertible Note) in the original total aggregate principal amount of
      not
      less than $250,000 and not more than $1,000,000.

     

    “Debentures”
mean
      Senior Secured Convertible Debentures or similar securities of the Company
      issued pursuant to a Qualified Debenture Financing.

     

    “Person”
means
      any person or entity of any nature whatsoever, specifically including an
      individual, a firm, a company, a corporation, a partnership, a limited liability
      company, a trust or other entity.

     

    “Qualified
      Debenture Financing”
shall
      mean the issuance by the Company of Debentures generating aggregate gross
      proceeds of not less than $4.0 million (with the unpaid principal and interest
      amounts of the Convertible Notes converted into such Debentures counted as
      part
      of such aggregate gross proceeds); provided, however, that if the economic
      terms
      of a Company financing are materially different in a manner detrimental to
      the
      holders of the Convertible Notes from the terms set forth in the proposed terms
      provided in writing to the holder of this Convertible Note on or prior to the
      date hereof, such financing shall not constitute a Qualified Debenture Financing
      without the consent of the Required Majority.

     

    
      
        
        

      

      
        5

        
          

        

      

      
        
        

      

    

     

    “Required
      Majority”
shall
      mean (i) Convertible Noteholders holding at least fifty percent (50%) of
      the total aggregate principal amount of the Convertible Notes then outstanding,
      and (ii) Harborview Master Fund LP (“Harborview”),
      for
      so long as Harborview continues to hold at least twenty-five percent (25%)
      of
      the total aggregate principal amount of the Convertible Notes then
      outstanding.

     

    “Security
      Agreement”
means
      the Security Agreement containing mutually agreed terms to be executed as of
      the
      date hereof by the Payee, Agent and the Company, as amended, modified or
      supplemented from time to time.

     

    “Securities
      Purchase Agreement”
means
      the Securities Purchase Agreement, dated as of the date hereof, between the
      Company and the Payee.

     

    9.  Adjustment
      Upon Certain Events.
      As a
      further inducement to the Payee to purchase this Convertible Note pursuant
      to
      the Securities Purchase Agreement, and in recognition of the substantial
      uncertainty associated with the Company’s ability to fully and timely perform
      its obligations under this Convertible Note, upon the occurrence of an Event
      of
      Default specified in Section 7(iii), (v), (vi) or (ix), the total amount of
      principal and interest then due under the terms of this Convertible Note shall
      be increased by fifty percent (50%). 

     

    10.  Expenses
      of Enforcement, etc.
      The
      Company agrees to pay all reasonable and documented fees and expenses incurred
      by the Payee in connection with the negotiation, execution and delivery of
      this
      Convertible Note, the Securities Purchase Agreement, and the Security Agreement
      (including the reasonable fees of counsel to the placement agent for the
      Payees). The Company agrees to pay all reasonable and documented fees and
      expenses incurred by the Payee in connection with any amendments, modifications,
      waivers, extensions, renewals, renegotiations or “workouts” of the provisions
      hereof or incurred by the Payee in connection with the enforcement or protection
      of its rights in connection with this Convertible Note, or in connection with
      any pending or threatened action, proceeding, or investigation relating to
      such
      enforcement or protection, including but not limited to the reasonable fees
      and
      disbursements of counsel for the Payee. 

     

    11.  Security
      Agreement.
      This
      Convertible Note shall be secured by the Security Agreement. Payee shall be
      entitled to all rights of a “Secured
      Party”
as
      defined in the Security Agreement.

     

    12.  No
      Rights as Shareholder.
      This
      Convertible Note, as such, shall not entitle the holder of the Convertible
      Note
      to any rights as a shareholder of the Company.

     

    13.  Amendment,
      Consent and Waiver.
      The
      provisions of this Convertible Note may not be modified, amended or waived,
      and
      the Company may not take any action herein prohibited, or omit to perform any
      act herein required to be performed by it, without the written consent of the
      Company and the Required Majority, at which time such modification, amendment
      or
      waiver shall be effective as to all Convertible Notes.

     

    
      
        
        

      

      
        6

        
          

        

      

      
        
        

      

    

     

    14.  Remedies
      Cumulative.
      No
      remedy herein conferred upon the Payee is intended to be exclusive of any other
      remedy and each and every such remedy shall be cumulative and shall be in
      addition to every other remedy given hereunder or now or hereafter existing
      at
      law or in equity or by statute or otherwise.

     

    15.  Remedies
      Not Waived.
      No
      course of dealing between the Company and the Payee or any delay on the part
      of
      the Payee in exercising any rights hereunder shall operate as a waiver of any
      right of the Payee.

     

    16.  Assignments.
      The
      Payee may assign, participate, transfer or otherwise convey this Convertible
      Note and any of its rights or obligations hereunder or interest herein to any
      affiliate of Payee and also to any other Person that the Company consents to
      (such consent not to be unreasonably withheld or delayed and
      may
      be conditioned on the Company’s satisfaction that all applicable laws shall have
      been complied with in connection with such transfer),
      and
      this Convertible Note shall inure to the benefit of the Payee’s successors and
      assigns. The Company shall not assign or delegate this Convertible Note or
      any
      of its liabilities or obligations hereunder.

     

    17.  Headings.
      The
      headings of the sections and paragraphs of this Convertible Note are inserted
      for convenience only and do not constitute a part of this Convertible
      Note.

     

    18.  Severability.
      If any
      provision of this Convertible Note is held invalid or unenforceable by any
      court
      of competent jurisdiction, the other provisions of this Convertible Note will
      remain in full force and effect. Any provision of this Convertible Note held
      invalid or unenforceable only in part or degree will remain in full force and
      effect to the extent not held invalid or unenforceable.

     

    19.  Cancellation.
      After
      all principal, premiums (if any) and accrued interest at any time owed on this
      Convertible Note have been paid in full, or this Convertible Note has been
      converted this Convertible Note will be surrendered to the Company for
      cancellation and will not be reissued.

     

    20.  Maximum
      Legal Rate.
      If at
      any time an interest rate applicable hereunder exceeds the maximum rate
      permitted by law, such rate shall be reduced to the maximum rate so permitted
      by
      law, and to the extent any interest payments have been previously paid relating
      to such excessive interest rate, such payments shall be deemed payments of
      principal hereunder.

     

    21.  Place
      of Payment and Notices.
      Subject
      to Section 5(i) above,
      payments of principal and interest are to be delivered to the Convertible
      Noteholder of this Convertible Note at the address provided by the Payee in
      the
      Securities Purchase Agreement, or at such other address as such Convertible
      Noteholder has specified by prior written notice to the Company. No notice
      shall
      be deemed to have been delivered until the first Business Day following actual
      receipt thereof at the foregoing address.

     

    22.  WAIVER
      OF JURY TRIAL.
      THE
      PAYEE AND THE COMPANY EACH HEREBY WAIVES ANY RIGHT IT MAY HAVE TO A TRIAL BY
      JURY IN RESPECT OF ANY LITIGATION DIRECTLY OR INDIRECTLY ARISING OUT OF, UNDER
      OR IN CONNECTION WITH THIS CONVERTIBLE NOTE AND/OR THE TRANSACTIONS CONTEMPLATED
      HEREUNDER.

     

    
      
        
        

      

      
        7

        
          

        

      

      
        
        

      

    

     

    23.  Submission
      to Jurisdiction.
      Any
      legal action or proceeding with respect to this Convertible Note shall be
      brought exclusively in the courts of the State of New York or of the United
      States of America sitting in New York County, and, by execution and delivery
      of
      this Convertible Note, the Company hereby accepts for itself and in respect
      of
      its property, generally and unconditionally, the jurisdiction of the aforesaid
      courts.

     

    (i)  The
      Company hereby irrevocably waives, in connection with any such action or
      proceeding, any objection, including, without limitation, any objection to
      the
      laying of venue or based on the grounds of forum non conveniens, which they
      may
      now or hereafter have to the bringing of any such action or proceeding in such
      respective jurisdictions.

     

    (ii)  Nothing
      herein shall affect the right of the Payee to serve process in any other manner
      permitted by law or to commence legal proceedings or otherwise proceed against
      the Company in any other jurisdiction.

     

    24.  Notices.
      Any
      notices, consents, waivers, or other communications required or permitted to
      be
      given under the terms of this Convertible Note shall be given in accordance
      with
      Section 5.7 of the Securities Purchase Agreement.

     

    25.  GOVERNING
      LAW.
      ALL
      ISSUES AND QUESTIONS CONCERNING THE CONSTRUCTION, VALIDITY, ENFORCEMENT AND
      INTERPRETATION OF THIS CONVERTIBLE NOTE SHALL BE GOVERNED BY, AND CONSTRUED
      IN
      ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK, WITHOUT GIVING EFFECT TO
      ANY
      CHOICE OF LAW OR CONFLICT OF LAW RULES OR PROVISIONS (WHETHER OF THE STATE
      OF
      NEW YORK OR ANY OTHER JURISDICTION) THAT WOULD CAUSE THE APPLICATION OF THE
      LAWS
      OF ANY JURISDICTION OTHER THAN THE STATE OF NEW YORK.

     

    
      
        
        

      

      
        8

        
          

        

      

      
        
        

      

    

    IN
      WITNESS WHEREOF, the Company has executed and delivered this Secured Convertible
      Promissory Note on the date first written above.

    
      	 	 	 
	 	
              COMPANY:

               

              CELSIA TECHNOLOGIES,
                INC.

            
	 
 	 
 	 
 
	
            	By:  	 
	 	
              

              Name:__________________________________

              Title:___________________________________

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