Document:

Exhibit 10.11

 

RIGHTS
AGREEMENT

 

Agreement
made as of __________, 2015 between Pacific Special Acquisition Corp., a British Virgin Islands Company, with offices at 40 Wall
Street, 28th Floor, New York, New York 10005 (the “Company”), and Continental Stock Transfer & Trust
Company, a New York corporation, with offices at 17 Battery Place, New York, New York 10004 (“Right Agent”).

 

WHEREAS,
the Company has received binding commitments from its sponsor (as defined in the Registration Statement) and EarlyBirdCapital,
Inc. (“EBC”) to purchase up to an aggregate of 416,875 units, each unit (“Unit”) comprised of one ordinary
share of the Company, no par value (“Ordinary Share”), one right to receive one-tenth of one Ordinary Share (“Right”)
upon the happening of the triggering event described herein, and one warrant to purchase one half ordinary share (“Warrant”),
and in connection therewith, will issue and deliver up to an aggregate of 416,875 Rights upon consummation of such private placement
(“Private Offering”); and

 

WHEREAS,
the Company is engaged in a public offering (“Public Offering”) of Units and, in connection therewith, will issue
and deliver up to 5,750,000 Rights to the public investors and 400,000 Rights (underlying unit purchase options) to EBC or its
designees; and

 

WHEREAS,
the Company has filed with the Securities and Exchange Commission (the “SEC”) a Registration Statement on Form S-1,
No. 333-206435 (“Registration Statement”), for the registration, under the Securities Act of 1933, as amended (“Act”)
of, among other securities, the Rights and the Ordinary Shares issuable to the holders of the Rights; and

 

WHEREAS,
the Company desires the Right Agent to act on behalf of the Company, and the Right Agent is willing to so act, in connection with
the issuance, registration, transfer and exchange of the Rights; and

 

WHEREAS,
the Company desires to provide for the form and provisions of the Rights, the terms upon which they shall be issued, and the respective
rights, limitation of rights, and immunities of the Company, the Right Agent, and the holders of the Rights; and

 

WHEREAS,
all acts and things have been done and performed which are necessary to make the Rights, when executed on behalf of the Company
and countersigned by or on behalf of the Right Agent, as provided herein, the valid, binding and legal obligations of the Company,
and to authorize the execution and delivery of this Agreement.

 

NOW,
THEREFORE, in consideration of the mutual agreements herein contained, the parties hereto agree as follows:

 

1.            Appointment
of Right Agent. The Company hereby appoints the Right Agent to act as agent for the Company for the Rights, and the Right
Agent hereby accepts such appointment and agrees to perform the same in accordance with the terms and conditions set forth in
this Agreement.

 

2.            Rights.

 

2.1.           Form
of Right. Each Right shall be issued in registered form only, shall be in substantially the form of Exhibit A hereto, the
provisions of which are incorporated herein and shall be signed by the Chairman of the Board or Chief Executive Officer and Treasurer,
Secretary or Assistant Secretary of the Company and shall bear a facsimile of the Company’s seal. In the event the person
whose facsimile signature has been placed upon any Right shall have ceased to serve in the capacity in which such person signed
the Right before such Right is issued, it may be issued with the same effect as if he or she had not ceased to be such at the
date of issuance.

 

2.2.           Effect
of Countersignature. Unless and until countersigned by the Right Agent pursuant to this Agreement, a Right shall be invalid
and of no effect and may not be exchanged for shares of Ordinary Shares.

 

     

    

    

 

2.3.           Registration.

 

 2.3.1.         Right
Register. The Right Agent shall maintain books (“Right Register”) for the registration of original issuance and
the registration of transfer of the Rights. Upon the initial issuance of the Rights, the Right Agent shall issue and register
the Rights in the names of the respective holders thereof in such denominations and otherwise in accordance with instructions
delivered to the Right Agent by the Company.

 

 2.3.2.         Registered
Holder. Prior to due presentment for registration of transfer of any Right, the Company and the Right Agent may deem and treat
the person in whose name such Right shall be registered upon the Right Register (“registered holder”) as the absolute
owner of such Right and of each Right represented thereby (notwithstanding any notation of ownership or other writing on the Right
Certificate made by anyone other than the Company or the Right Agent), for the purpose of the exchange thereof, and for all other
purposes, and neither the Company nor the Right Agent shall be affected by any notice to the contrary.

 

2.4.           Detachability
of Rights. The securities comprising the Units, including the Rights, will not be separately transferable until the ninetieth
(90th) day after the date hereof unless EBC informs the Company of its decision to allow earlier separate trading,
but in no event will separate trading of the securities comprising the Units begin until (i) the Company files a Current Report
on Form 8-K which includes an audited balance sheet reflecting the receipt by the Company of the gross proceeds of the Public
Offering including the proceeds received by the Company from the exercise of the over-allotment option, if the over-allotment
option is exercised on the date hereof, and (ii) the Company issues a press release and files a Current Report on Form 8-K announcing
when such separate trading shall begin.

 

3.      
     Terms and Exchange of Rights

 

3.1.           Rights.
Each Right shall entitle the holder thereof to receive one-tenth of one Ordinary Share upon the happening of an Exchange Event
(described below). No additional consideration shall be paid by a holder of Rights in order to receive his, her or its shares
of Ordinary Shares upon an Exchange Event as the purchase price for such shares of Ordinary Shares has been included in the purchase
price for the Units. In no event will the Company be required to net cash settle the Rights or issue fractional Ordinary Shares.

  

3.2.           Exchange
Event. An Exchange Event shall occur upon the Company’s consummation of an initial Business Combination (as defined
in the Company’s Amended and Restated Memorandum and Articles of Association).

 

3.3.      
   Exchange of Rights.

 

3.3.1.         Issuance
of Certificates. As soon as practicable upon the occurrence of an Exchange Event, the Company shall direct holders of the
Rights to return their Rights Certificates to the Right Agent. Upon receipt of a valid Rights Certificate, the Company shall issue
to the registered holder of such Right(s) the number of full Ordinary Shares to which he, she or it is entitled, registered in
such name or names as may be directed by him, her or it and issue to such registered holder(s) a certificate for the such shares.
Notwithstanding the foregoing, or any provision contained in this Rights Agreement to the contrary, in no event will the Company
be required to net cash settle the Rights. The Company shall not issue fractional shares upon exchange of Rights. In the event
that any holder would otherwise be entitled to any fractional share upon exchange of Rights, at the time of an Exchange Event,
the Company will instruct the Right Agent how any such entitlement will be addressed. To the fullest extent permitted by the Company's
Amended and Restated Memorandum and Articles of Association the Company reserves the right to deal with any such fractional entitlement
at the relevant time in any manner permitted by the Act and the Amended and Restated Memorandum and Articles, which would include
the rounding down of any entitlement to receive Ordinary Shares to the nearest whole share (and in effect extinguishing any fractional
entitlement), or the holder being entitled to hold any remaining fractional entitlement (without any share being issued) and to
aggregate the same with any future fractional entitlement to receive shares in the Company until the holder is entitled to receive
a whole number. Any rounding down and extinguishment may be done with or without any in lieu cash payment or other compensation
being made to the holder of the relevant Rights, such that value received on exchange of the Rights may be considered less than
the value that the holder would otherwise expect to receive.

 

    	 	2	 

    

    

 

3.3.2.         Valid
Issuance. All Ordinary Shares issued upon an Exchange Event in conformity with this Agreement shall be validly issued, fully
paid and nonassessable.

 

3.3.3.         Date
of Issuance. Each person in whose name any such certificate for Ordinary Shares is issued shall for all purposes be deemed
to have become the holder of record of such shares on the date of the Exchange Event, irrespective of the date of delivery of
such certificate.

 

3.3.4          Company
Not Surviving Following Exchange Event. Upon an Exchange Event in which the Company does not continue as the publicly held
reporting entity, the definitive agreement will provide for the holders of Rights to receive the same per share consideration
the holders of the Ordinary Shares will receive in such transaction, for the number of shares such holder is entitled to pursuant
to Section 3.3.1 above. Each holder of a Right will be required to affirmatively convert his/her or its rights in order to receive
the 1/10 share underlying each right (without paying any additional consideration) upon consummation of the Exchange Event. Each
holder of a Right will be required to indicate his, her or its election to convert the Rights into underlying shares as well as
to return the original certificates evidencing the Rights to the Company.

 

3.5           Duration
of Rights. If an Exchange Event does not occur within the time period set forth in the Company’s Amended and Restated
Memorandum and Articles of Association, as the same may be amended from time to time, the Rights shall expire and shall be worthless.

 

4.      
     Transfer and Exchange of Rights.

 

4.1.          Registration
of Transfer. The Right Agent shall register the transfer, from time to time, of any outstanding Right upon the Right Register,
upon surrender of such Right for transfer, properly endorsed with signatures properly guaranteed and accompanied by appropriate
instructions for transfer. Upon any such transfer, a new Right representing an equal aggregate number of Rights shall be issued
and the old Right shall be cancelled by the Right Agent. The Rights so cancelled shall be delivered by the Right Agent to the
Company from time to time upon request.

 

4.2.          Procedure
for Surrender of Rights. Rights may be surrendered to the Right Agent, together with a written request for exchange or transfer,
and thereupon the Right Agent shall issue in exchange therefor one or more new Rights as requested by the registered holder of
the Rights so surrendered, representing an equal aggregate number of Rights; provided, however, that in the event that a Right
surrendered for transfer bears a restrictive legend, the Right Agent shall not cancel such Right and issue new Rights in exchange
therefor until the Right Agent has received an opinion of counsel for the Company stating that such transfer may be made and indicating
whether the new Rights must also bear a restrictive legend.

 

4.3.          Fractional
Rights. The Right Agent shall not be required to effect any registration of transfer or exchange which will result in the
issuance of a Right Certificate for a fraction of a Right.

 

4.4.          Service
Charges. No service charge shall be made for any exchange or registration of transfer of Rights.

 

4.5.          Right
Execution and Countersignature. The Right Agent is hereby authorized to countersign and to deliver, in accordance with the
terms of this Agreement, the Rights required to be issued pursuant to the provisions of this Section 4, and the Company, whenever
required by the Right Agent, will supply the Right Agent with Rights duly executed on behalf of the Company for such purpose.

 

5.            Other
Provisions Relating to Rights of Holders of Rights.

 

5.1.          No
Rights as Shareholder. Until exchange of a Right for shares of Ordinary Shares as provided for herein, a Right does not entitle
the registered holder thereof to any of the rights of a shareholder of the Company, including, without limitation, the right to
receive dividends, or other distributions, exercise any preemptive rights to vote or to consent or to receive notice as shareholders
in respect of the meetings of shareholders or the election of directors of the Company or any other matter.

 

    	 	3	 

    

    

 

5.2.          Lost,
Stolen, Mutilated, or Destroyed Rights. If any Right is lost, stolen, mutilated, or destroyed, the Company and the Right Agent
may on such terms as to indemnity or otherwise as they may in their discretion impose (which shall, in the case of a mutilated
Right, include the surrender thereof), issue a new Right of like denomination, tenor, and date as the Right so lost, stolen, mutilated,
or destroyed. Any such new Right shall constitute a substitute contractual obligation of the Company, whether or not the allegedly
lost, stolen, mutilated, or destroyed Right shall be at any time enforceable by anyone.

 

5.3.          Reservation
of Ordinary Shares. The Company shall at all times reserve and keep available a number of its authorized but unissued shares
of Ordinary Shares that will be sufficient to permit the exchange of all outstanding Rights issued pursuant to this Agreement.

 

6.            Concerning
the Right Agent and Other Matters.

 

6.1.          Payment
of Taxes. The Company will from time to time promptly pay all taxes and charges that may be imposed upon the Company or the
Right Agent in respect of the issuance or delivery of shares of Ordinary Shares upon the exchange of Rights, but the Company shall
not be obligated to pay any transfer taxes in respect of the Rights or such shares.

 

6.2.          Resignation,
Consolidation, or Merger of Right Agent.

 

6.2.1.           Appointment
of Successor Right Agent. The Right Agent, or any successor to it hereafter appointed, may resign its duties and be discharged
from all further duties and liabilities hereunder after giving sixty (60) days’ notice in writing to the Company. If the
office of the Right Agent becomes vacant by resignation or incapacity to act or otherwise, the Company shall appoint in writing
a successor Right Agent in place of the Right Agent. If the Company shall fail to make such appointment within a period of 30
days after it has been notified in writing of such resignation or incapacity by the Right Agent or by the holder of the Right
(who shall, with such notice, submit his, her or its Right for inspection by the Company), then the holder of any Right may apply
to the Supreme Court of the State of New York for the County of New York for the appointment of a successor Right Agent at the
Company’s cost. Any successor Right Agent, whether appointed by the Company or by such court, shall be a corporation organized
and existing under the laws of the State of New York, in good standing and having its principal office in the Borough of Manhattan,
City and State of New York, and authorized under such laws to exercise corporate trust powers and subject to supervision or examination
by federal or state authority. After appointment, any successor Right Agent shall be vested with all the authority, powers, rights,
immunities, duties, and obligations of its predecessor Right Agent with like effect as if originally named as Right Agent hereunder,
without any further act or deed; but if for any reason it becomes necessary or appropriate, the predecessor Right Agent shall
execute and deliver, at the expense of the Company, an instrument transferring to such successor Right Agent all the authority,
powers, and rights of such predecessor Right Agent hereunder; and upon request of any successor Right Agent the Company shall
make, execute, acknowledge, and deliver any and all instruments in writing for more fully and effectually vesting in and confirming
to such successor Right Agent all such authority, powers, rights, immunities, duties, and obligations.

 

6.2.2.           Notice
of Successor Right Agent. In the event a successor Right Agent shall be appointed, the Company shall give notice thereof to
the predecessor Right Agent and the transfer agent for the Ordinary Shares not later than the effective date of any such appointment.

 

6.2.3.           Merger
or Consolidation of Right Agent. Any corporation into which the Right Agent may be merged or with which it may be consolidated
or any corporation resulting from any merger or consolidation to which the Right Agent shall be a party shall be the successor
Right Agent under this Agreement without any further act.

 

6.3.    
     Fees and Expenses of Right Agent.

 

6.3.1.           Remuneration.
The Company agrees to pay the Right Agent reasonable remuneration for its services as such Right Agent hereunder and will reimburse
the Right Agent upon demand for all expenditures that the Right Agent may reasonably incur in the execution of its duties hereunder.

 

    	 	4	 

    

    

 

6.3.2.           Further
Assurances. The Company agrees to perform, execute, acknowledge, and deliver or cause to be performed, executed, acknowledged,
and delivered all such further and other acts, instruments, and assurances as may reasonably be required by the Right Agent for
the carrying out or performing of the provisions of this Agreement.

 

6.4.         Liability
of Right Agent.

 

6.4.1.           Reliance
on Company Statement. Whenever in the performance of its duties under this Right Agreement, the Right Agent shall deem it
necessary or desirable that any fact or matter be proved or established by the Company prior to taking or suffering any action
hereunder, such fact or matter (unless other evidence in respect thereof be herein specifically prescribed) may be deemed to be
conclusively proved and established by a statement signed by the Chief Executive Officer or Chief Financial Officer and delivered
to the Right Agent. The Right Agent may rely upon such statement for any action taken or suffered in good faith by it pursuant
to the provisions of this Agreement. 

 

6.4.2.           Indemnity.
The Right Agent shall be liable hereunder only for its own gross negligence, willful misconduct or bad faith. The Company agrees
to indemnify the Right Agent and save it harmless against any and all liabilities, including judgments, costs and reasonable counsel
fees, for anything done or omitted by the Right Agent in the execution of this Agreement except as a result of the Right Agent’s
gross negligence, willful misconduct, or bad faith.

 

6.4.3.           Exclusions.
The Right Agent shall have no responsibility with respect to the validity of this Agreement or with respect to the validity or
execution of any Right (except its countersignature thereof); nor shall it be responsible for any breach by the Company of any
covenant or condition contained in this Agreement or in any Right; nor shall it by any act hereunder be deemed to make any representation
or warranty as to the authorization or reservation of any Ordinary Shares to be issued pursuant to this Agreement or any Right
or as to whether any Ordinary Shares will when issued be valid and fully paid and nonassessable.

 

6.5.           Acceptance
of Agency. The Right Agent hereby accepts the agency established by this Agreement and agrees to perform the same upon the
terms and conditions herein set forth.

 

6.6.          Waiver.
The Right Agent hereby waives any right of set-off or any other right, title, interest or claim of any kind (“Claim”)
in, or to any distribution of, the Trust Account (as defined in that certain Investment Management Trust Agreement, dated as of
the date hereof, by and between the Company and the Right Agent as trustee thereunder) and hereby agrees not to seek recourse,
reimbursement, payment or satisfaction for any Claim against the Trust Account for any reason whatsoever.

 

7.            Miscellaneous
Provisions.

 

7.1.           Successors.
All the covenants and provisions of this Agreement by or for the benefit of the Company or the Right Agent shall bind and inure
to the benefit of their respective successors and assigns.

 

7.2.           Notices.
Any notice, statement or demand authorized by this Right Agreement to be given or made by the Right Agent or by the holder of
any Right to or on the Company shall be sufficiently given when so delivered if by hand or overnight delivery or if sent by certified
mail or private courier service within five days after deposit of such notice, postage prepaid, addressed (until another address
is filed in writing by the Company with the Right Agent), as follows:

 

Pacific
Special Acquisition Corp.

40 Wall
Street, 28th Floor

New York,
New York 10005

Attn: Zhouhong
Peng, Chief Executive Officer

and Chief
Financial Officer

 

    	 	5	 

    

    

 

Any
notice, statement or demand authorized by this Agreement to be given or made by the holder of any Right or by the Company to or
on the Right Agent shall be sufficiently given when so delivered if by hand or overnight delivery or if sent by certified mail
or private courier service within five days after deposit of such notice, postage prepaid, addressed (until another address is
filed in writing by the Right Agent with the Company), as follows:

 

Continental
Stock Transfer & Trust Company 

17 Battery Place

New York,
New York 10004

Attn: Compliance
Department

 

with a copy
in each case to:

 

Ellenoff
Grossman & Schole, LLP

1345 Avenue
of the Americas,

New York,
NY 10105

Attn: Stuart
Neuhauser, Esq.

 

and

 

Graubard
Miller

405 Lexington
Avenue

New
York, New York 10174

Attn: David Alan Miller, Esq.

 

and

 

EarlyBirdCapital,
Inc.

275 Madison
Avenue, 27th Floor

New York,
New York 10016

Attn: David
M. Nussbaum, Chairman

 

7.3.           Applicable
Law. The validity, interpretation, and performance of this Agreement and of the Rights shall be governed in all respects by
the laws of the State of New York, without giving effect to conflicts of law principles that would result in the application of
the substantive laws of another jurisdiction. The Company hereby agrees that any action, proceeding or claim against it arising
out of or relating in any way to this Agreement shall be brought and enforced in the courts of the State of New York or the United
States District Court for the Southern District of New York, and irrevocably submits to such jurisdiction, which jurisdiction
shall be exclusive. The Company hereby waives any objection to such exclusive jurisdiction and that such courts represent an inconvenience
forum. Any such process or summons to be served upon the Company may be served by transmitting a copy thereof by registered or
certified mail, return receipt requested, postage prepaid, addressed to it at the address set forth in Section 9.2 hereof. Such
mailing shall be deemed personal service and shall be legal and binding upon the Company in any action, proceeding or claim.

 

7.4.           Persons
Having Rights under this Agreement. Nothing in this Agreement expressed and nothing that may be implied from any of the provisions
hereof is intended, or shall be construed, to confer upon, or give to, any person or corporation other than the parties hereto
and the registered holders of the Rights and, for the purposes of Sections 3.1, 7.4 and 7.8 hereof, EBC, any right, remedy, or
claim under or by reason of this Right Agreement or of any covenant, condition, stipulation, promise, or agreement hereof. EBC
shall be deemed to be a third-party beneficiary of this Agreement with respect to Sections 3.1, 7.4 and 7.8 hereof. All covenants,
conditions, stipulations, promises, and agreements contained in this Right Agreement shall be for the sole and exclusive benefit
of the parties hereto (and EBC with respect to the Sections 3.1, 7.4 and 7.8 hereof) and their successors and assigns and of the
registered holders of the Rights.

 

7.5.           Examination
of the Right Agreement. A copy of this Agreement shall be available at all reasonable times at the office of the Right Agent
in the Borough of Manhattan, City and State of New York, for inspection by the registered holder of any Right. The Right Agent
may require any such holder to submit his, her or its Right for inspection by it.

 

7.6.           Counterparts.
This Agreement may be executed in any number of original or facsimile counterparts and each of such counterparts shall for all
purposes be deemed to be an original, and all such counterparts shall together constitute but one and the same instrument.

 

7.7.           Effect
of Headings. The Section headings herein are for convenience only and are not part of this Right Agreement and shall not affect
the interpretation thereof.

 

7.8.          Amendments.
This Agreement may be amended by the parties hereto without the consent of any registered holder for the purpose of curing any
ambiguity, or of curing, correcting or supplementing any defective provision contained herein or adding or changing any other
provisions with respect to matters or questions arising under this Agreement as the parties may deem necessary or desirable and
that the parties deem shall not adversely affect the interest of the registered holders. All other modifications or amendments
shall require the written consent or vote of the registered holders of a majority of the then outstanding Rights. The provisions
of this Section 7.8 may not be modified, amended or deleted without the prior written consent of EBC.

 

7.9.          Severability.
This Right Agreement shall be deemed severable, and the invalidity or unenforceability of any term or provision hereof shall not
affect the validity or enforceability of this Right Agreement or of any other term or provision hereof. Furthermore, in lieu of
any such invalid or unenforceable term or provision, the parties hereto intend that there shall be added as a part of this Right
Agreement a provision as similar in terms to such invalid or unenforceable provision as may be possible and be valid and enforceable.

 

[Signature
Page Follows]

 

    	 	6	 

    

    

 

 

IN
WITNESS WHEREOF, this Agreement has been duly executed by the parties hereto as of the day and year first above written.

 

	 	PACIFIC
    SPECIAL ACQUISITION CORP.
	 	 	 
	 	By:	 
	 	 	Name: Zhouhong
    Peng
	 	 	Title: Chief
    Executive Officer and Chief Financial Officer
	 	 	 
	 	CONTINENTAL
    STOCK TRANSFER & TRUST COMPANY
	 	 	 
	 	By:	 
	 	 	Name:
	 	 	Title:

 

 

 

7ex41.htm

VET ONLINE SUPPLY, INC.

 SUBSCRIPTION AGREEMENT

The Investor named below, by payment of the purchase price for such Common Shares, by the delivery of a check payable to VET ONLINE SUPPLY, INC. (the "Company"), hereby subscribes for the purchase of the number of Common Shares indicated below of VET ONLINE SUPPLY, INC. , at a purchase of $0.10 per Share as set forth in the Prospectus.

By such payment, the named Investor further acknowledges receipt of the Prospectus and the Subscription Agreement, the terms of which govern the investment in the Common Shares

being subscribed for hereby.

A. INVESTMENT:               (1) Number of Shares ___________________________

(2) Date of Investor's check _______________________

B. REGISTRATION:

(3) Registered owner: __________________________

Co-Owner: __________________________________

(4) Mailing address: ___________________________

City, State & zip: _________________________

(5) Residence Address (if different from above):

=================================================

(6) Birth Date: ______/______/______

(7) Employee or Affiliate: Yes ______ No ______

(8) Social Security: #: ______/______/______

U.S. Citizen [ ] Other [ ]

Co-Owner Social Security:

#: ______/______/______

U.S. Citizen [ ] Other [ ]

Corporate or Custodial:

Taxpayer ID #: ______/______/______

U.S. Citizen [ ] Other [ ]

(9) Telephone (H) ( ) ______________________

(10) *email address:__________________________

*Please note that by providing your email address, you accept that all further communications between you and the Company shall be by email, unless otherwise required by law and/or the rules and regulations of any governing body of traded securities.

  

1

  

C. OWNERSHIP

[ ] Individual Ownership                        [ ] IRA or Keogh

[ ] Joint Tenants with Rights of Survivorship

[ ] Trust/Date Trust Established_______________

[ ] Pension/Trust (S.E.P.)

[ ] Tenants in Common                                           [ ] Tenants by the Entirety

[ ] Corporate Ownership                                         [ ] Partnership

[ ] Other_____________________

D. SIGNATURES

Registered Owner: _____________________________

Co-Owner: _____________________________

Print Name of Custodian or Trustee: _____________________________

Authorized Signature: _____________________________

Date: _____________________

Signature: ___________________________________

MAIL TO:                              VET ONLINE SUPPLY, INC. 

            9612 West Hawthorne

                                        Crystal River, Florida 34428

 

 

____________________________________________________________________

FOR OFFICE USE ONLY:

Date Received: ________________________________________________

Date Accepted/Rejected ________________________________________

Subscriber's Check Amount: _______________________

Check No. ___________________ Date Check ________________

 

  

2

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