Document:

dais_ex101.htm

EXHIBIT 10.1

 

AMENDMENT TO SECURITIES PURCHASE AGREEMENT

 

This Amendment, dated as of December 28, 2012 (this “Amendment”), made and entered into by and between Dais Analytic Corporation, a New York corporation with its principal executive offices located at 11552 Prosperous Drive, Odessa, Florida 33556 (the “Company”), and Green Valley International Investment Management Company Limited, a company organized in Hong Kong with a US address of 951 Old Country Road, Belmont, CA 94002  (the “Purchaser”) amends the Securities Purchase Agreement, dated as of October 17, 2012 (the “Securities Purchase Agreement”), by and between the Company and the Purchaser. Capitalized terms used but not defined herein shall have the meanings ascribed to such terms in the Securities Purchase Agreement.

 

WHEREAS, the Company and the Purchaser have determined that it is necessary, desirable and in the best interest of the Company and the Purchaser to amend the Securities Purchase Agreement as set forth in this Amendment.

 

NOW THEREFORE, in consideration of the foregoing and the representations, warranties, covenants and agreements herein contained, the Company and the Purchaser hereby agree as follows:

 

1. Section 1 is hereby amended and restated in its entirety as follows:

 

In addition to Shares and Warrants previously purchased from the Company by the Purchaser, purchased for $1,750,000, within one Business Day of the satisfaction of the conditions in Section 6 and Section 7 (other than Section 7(l)) set forth in this Agreement but no later than January 25, 2013 (the “Closing Date”), the Company shall issue and sell to the Purchaser and the Purchaser agrees to purchase from the Company an additional 52,500,000 Shares and Warrants to purchase up to 13,125,000 Warrant Shares for an aggregate purchase price of $5,250,000.

 

2. Section 4(c) is hereby amended and restated in its entirety as follows:

 

 (c) Use of Proceeds. The Company shall use $4.0 million of the proceeds from the sale of the Shares to repay the unsecured note and accrued interest to Platinum-Montaur Life Sciences, LLC and for capital expenditures, working capital, and general business purposes. The Company shall use $3.0 million of the proceeds from the sale of the Shares to create and capitalize a wholly owned subsidiary to be organized and located in China (the “Dais China Subsidiary”).

 

3. Section 4(i) is hereby amended and restated in its entirety as follows:

 

(i) Nomination of Directors. After the Closing Date, the Purchaser shall have the right to propose two (2) candidates for the Company’s Board of Directors. After such nomination, the Company’s Board of Directors or an appropriate committee of the Board of Directors, acting in good faith within ten Business Days after the later of receiving the written nomination by the Purchaser the nominee’s completed director and officer questionnaire, and the results of a standard background check, shall appoint the Purchaser’s nominee to the Board of Directors; provided that, the Company shall not be obligated to appoint any nominee of Purchaser if (i) the nomination of such nominee would violate rules, regulations or other standards of the SEC or the Company’s Trading Market, or (ii) the nominee is not approved by the Company’s director and officer insurance carrier. Following such appointment, the Company’s Board of Directors or an appropriate committee of the Board of Directors shall include the Purchaser’s nominees on the slate of directors recommended to the Board for nomination for election by the Company’s stockholders at the each annual meeting of the Company’s stockholders; provided that the Purchaser continues to own at least 50% of the Shares it purchased pursuant to this Agreement.

 

  

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4. Section 8(a)(ii) is hereby amended and restated in its entirety as follows:

 

(ii) By the Company if any of the conditions set forth in Section 6 shall have become incapable of fulfillment, and shall not have been waived by the Company or if the Closing Date does not occur by January 31, 2013;

 

5. This Amendment is effective as of the date hereof, and all references to the Securities Purchase Agreement from and after such time will be deemed to be references to the Securities Purchase Agreement as amended hereby.

 

6. The Securities Purchase Agreement is not otherwise supplemented or amended by virtue of this Amendment, but remains in full force and effect.

 

7. This Agreement shall be governed by, and construed in accordance with, the internal laws of the State of New York without regard to the choice of law principles thereof. Each of the parties hereto irrevocably submits to the exclusive jurisdiction of the courts of the State of New York located in New York County and the United States District Court for the Southern District of New York for the purpose of any suit, action, proceeding or judgment relating to or arising out of this Agreement and the transactions contemplated hereby. Service of process in connection with any such suit, action or proceeding may be served on each party hereto anywhere in the world by the same methods as are specified for the giving of notices under this Agreement. Each of the parties hereto irrevocably consents to the jurisdiction of any such court in any such suit, action or proceeding and to the laying of venue in such court. Each party hereto irrevocably waives any objection to the laying of venue of any such suit, action or proceeding brought in such courts and irrevocably waives any claim that any such suit, action or proceeding brought in any such court has been brought in an inconvenient forum. EACH OF THE PARTIES HERETO WAIVES ANY RIGHT TO REQUEST A TRIAL BY JURY IN ANY LITIGATION WITH RESPECT TO THIS AGREEMENT AND REPRESENTS THAT COUNSEL HAS BEEN CONSULTED SPECIFICALLY AS TO THIS WAIVER.

8. This Amendment may be executed in any number of 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. A signature to this Amendment transmitted electronically shall have the same authority, effect and enforceability as an original signature.

 

9. If any term, provision, covenant or restriction of this Amendment or applicable to this Amendment is held by a court of competent jurisdiction or other authority to be invalid, null and void or unenforceable, the remainder of the terms, provisions, covenants and restrictions of this Amendment shall remain in full force and effect and shall in no way be affected, impaired or invalidated; provided, further, that if any such excluded term, provision, covenant or restriction shall adversely affect the rights, immunities, duties or obligations of the Rights Agent, the Rights Agent shall be entitled to resign immediately.

 

 

[Signature page follows]

 

  

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IN WITNESS WHEREOF, the Purchaser and the Company have caused this Securities Purchase Agreement to be duly executed as of the date first above written.

 

	
DAIS ANALYTIC CORPORATION

	  
	By:	
/s/ Timothy N. Tangredi                                             

	  	
Name: Timothy N. Tangredi

	  	
Title: Chief Executive Officer and President

	
GREEN VALLEY INTERNATIONAL INVESTMENT MANAGEMENT COMPANY LIMITED

	  	  
	 	  	  
	By:	/s/ Fuying Yu                                                                 	 
	  	
Name: Mr. Fuying Yu

	  
	  	
Title: Chairman

	  

 

 

 

 

 3amplitech_ex41.htm

EXHIBIT 4.1

 

NEITHER THIS SECURITY NOR THE SECURITIES FOR WHICH THIS SECURITY IS CONVERTIBLE HAVE BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.

 

AMPLITECH GROUP, INC.

 

PROMISSORY NOTE

 

No._______________

 

Date of Issuance: August 13, 2012 Principal Amount: $ _________.00

FOR VALUE RECEIVED AmpliTech Group, Inc., a Nevada corporation (the “Company”), promises to pay to __________ (“Holder”), or its registered assigns, the principal sum of ________________________ No/100 Dollars ($__________.00) (as reduced pursuant to the terms hereof pursuant to prepayment, conversion or otherwise, the “Principal”) when due, whether upon the Maturity Date (as defined below), acceleration, prepayment or otherwise (in each case in accordance with the terms hereof) and to pay interest (“Interest”) on any outstanding Principal at the applicable Interest Rate (as defined below) from the date set out above as the Issuance Date (the “Issuance Date”) until the same becomes due and payable, whether upon the Maturity Date, acceleration, conversion, prepayment or otherwise (in each case in accordance with the terms hereof).

 

Section 1. Payment of Principal.  On the Maturity Date, the Company shall pay to the Holder an amount in cash representing all outstanding Principal, accrued and unpaid Interest and accrued and unpaid late charges on such Principal and Interest.  For purposes of this Note, “Maturity Date” means _____________.

 

Section 2. Interest; Interest Rate.  Interest on this Note shall commence accruing on the Issuance Date at the Interest Rate (as defined below) on the outstanding Principal amount from time to time and shall be computed on the basis of a 365-day year and shall compound each calendar quarter and shall be payable in accordance with the terms of this Note and shall be payable to the Holder of this Note on the Maturity Date.  For purposes of this Note, “Interest Rate” means eight percent (8%) per annum.

 

Section 3. Payment.  Payments due hereunder shall be made in lawful tender of the United States.  All payments due hereunder shall be made by the Company to Holder at the address set forth in Section 17 below, or at such other place as the Holder may from time to time designate in writing.

 

  

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Section 4. Conversion Right.

 

	
(a)    

	
Subject to other provisions of Section 4 hereof, at any time or times on or after the Issuance Date, the Holder shall be entitled to convert any portion of the outstanding and unpaid Conversion Amount (as defined below) into validly issued, fully paid and non-assessable shares of the Company’s common stock, par value per share $0.001 (the “Common Stock”) at the Conversion Rate (as defined below) by (i) delivering written notice in the form attached hereto as Exhibit A to the Company that such Holder elects to exercise the conversion right pursuant to this Section 4(a) and specifying the Conversion Amount to be converted and the name or names (with address) in which a certificate or certificates for shares of Common Stock are to be issued (the “Conversion Notice”); and (ii)  surrendering this Note to the Company.  For purpose of this Note, “Conversion Amount” means the portion of the Principal to be converted plus all accrued and unpaid Interest with respect to such portion of the Principal and accrued and unpaid late charges with respect to such portion of such Principal and such Interest, if any.  For purposes of this Note, “Conversion Rate” means the number of shares of Common Stock issuable upon conversion of any Conversion Amount determined by dividing (x) such Conversion Amount by (y) $0.10 per share, subject to adjustment as provided herein (the “Conversion Price”).

 

	
(b)    

	
As soon as practicable after receipt of the Conversion Notice and the surrender of this Note for such shares of Common Stock (the “Conversion Date”), the Company shall issue and deliver to such Holder, or to his, her or its nominees, a certificate or certificates for the number of full shares of Common Stock issuable to such Holder on such conversion in accordance with the provisions hereof.  The Company shall not issue any fraction of a share of Common Stock upon any conversion.  If the issuance would result in the issuance of a fraction of a share of Common Stock, the Company shall round such fraction of a share of Common Stock up to the nearest whole share.

 

	
(c)    

	
In the event of a partial conversion of this Note pursuant hereto, the Company shall issue a new Note to the Holder.  Such new Note (i) shall be of like tenor with this Note, (ii) shall have a principal amount equal to the Principal of this Note less the Conversion Amount set forth in the applicable Conversion Notice, (iii) shall have an issuance date, as indicated on the face of such new Note which is the same as the Issuance Date, and (iv) shall have the same rights and conditions as this Note.

 

	
(d)    

	
Each conversion exercised in accordance with this Section 4 shall be deemed to have been effected immediately prior to the close of business on the Conversion Date.

 

  

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(e)    

	
The Company shall not effect conversion  of any Conversion Amount, and a Holder shall not have the right to convert any portion of this Conversion Amount, pursuant to Section 4 or otherwise, to the extent that after giving effect to such issuance after conversion as set forth on the applicable Conversion Notice, the Holder (together with the Holder’s Affiliates, and any other Persons acting as a group together with the Holder or any of the Holder’s Affiliates), would beneficially own in excess of the Beneficial Ownership Limitation (as defined below).  For purposes of the foregoing sentence, the number of shares of Common Stock beneficially owned by the Holder and its Affiliates shall include the number of shares of Common Stock issuable upon conversion with respect to which such determination is being made, but shall exclude the number of shares of Common Stock which would be issuable upon (i) conversion of the remaining, nonconverted portion of Conversion Amount beneficially owned by the Holder or any of its Affiliates and (ii) exercise or conversion of the unexercised or nonconverted portion of any other securities of the Company (including, without limitation, any other  Common Stock Equivalents) subject to a limitation on conversion or exercise analogous to the limitation contained herein beneficially owned by the Holder or any of its Affiliates.  Except as set forth in the preceding sentence, for purposes of this Section 4(e), beneficial ownership shall be calculated in accordance with Section 13(d) of the Exchange Act and the rules and regulations promulgated thereunder, it being acknowledged by the Holder that the Company is not representing to the Holder that such calculation is in compliance with Section 13(d) of the Exchange Act and the Holder is solely responsible for any schedules required to be filed in accordance therewith.   To the extent that the limitation contained in this Section 4(e) applies, the determination of whether the Conversion Amount is exercisable (in relation to other securities owned by the Holder together with any Affiliates) and of which portion of the Conversion Amount is exercisable shall be in the sole discretion of the Holder, and the submission of a Notice of Exercise shall be deemed to be the Holder’s determination of whether the Conversion Amount is convertible (in relation to other securities owned by the Holder together with any Affiliates) and of which portion of the Conversion Amount is convertible, in each case subject to the Beneficial Ownership Limitation, and the Company shall have no obligation to verify or confirm the accuracy of such determination.   In addition, a determination as to any group status as contemplated above shall be determined in accordance with Section 13(d) of the Exchange Act and the rules and regulations promulgated thereunder.  The “Beneficial Ownership Limitation” shall be 4.99% of the number of shares of the Common Stock outstanding immediately after giving effect to the issuance of shares of Common Stock issuable upon conversion of the Conversion Amount.  The Holder, upon not less than 61 days’ prior notice to the Company, may increase or decrease the Beneficial Ownership Limitation provisions of this Section 2(e), provided that the Beneficial Ownership Limitation in no event exceeds 9.99% of the number of shares of the Common Stock outstanding immediately after giving effect to the issuance of shares of Common Stock upon conversion of the Conversion Amount held by the Holder and the provisions of this Section 2(e) shall continue to apply.  Any such increase or decrease will not be effective until the 61st day after such notice is delivered to the Company.  The limitations contained in this paragraph shall apply to a successor holder of this Note.

 

Section 5. Piggyback Registration.

 

	
(a)    

	
Whenever the Company proposes to register any shares of its Common Stock under the Securities Act (other than a registration effected to implement a primary underwritten offering on behalf of the Company or an employee benefit plan or a transaction to which Rule 145 of the Securities Act is applicable, or a Registration Statement on Form S-4, S-8 or any successor form thereto or another form not available for registering the Registrable Securities (as defined below) for sale to the public), whether for its own account or for the account of one or more stockholders of the Company and the form of registration statement to be used may be used for any registration of Registrable Securities (a “Piggyback Registration”), the Company shall give prompt written notice (in any event no later than five days prior to the filing of such Registration Statement) to the holders of Registrable Securities of its intention to effect such a registration and, subject to Section 5(b) and Section 5(c), shall include in such registration all Registrable Securities with respect to which the Company has received written requests for inclusion from the holders of Registrable Securities. The Company may postpone or withdraw the filing or the effectiveness of a Piggyback Registration at any time in its sole discretion. The “Registrable Securities” means (a) any shares of Common Stock held by the Holder or issuable upon conversion, of the Conversion Amount. As to any particular Registrable Securities, such securities shall cease to be Registrable Securities when (i) a registration statement covering such securities has been declared effective by the Securities Exchange Commission and such securities have been disposed of pursuant to such effective registration statement, (ii) such securities are sold under circumstances in which all of the applicable conditions of Rule 144 (or any similar provisions then in force) under the Securities Act are met, (iii) such securities are otherwise transferred and such securities may be resold without subsequent registration under the Securities Act, or (iv) such securities shall have ceased to be outstanding.

 

  

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(b)    

	
 If a Piggyback Registration is initiated as an underwritten offering on behalf of a holder of Common Stock other than Registrable Securities, and the managing underwriter advises the Company in writing that in its opinion the number of shares of Common Stock proposed to be included in such registration, including all Registrable Securities and all other shares of Common Stock proposed to be included in such underwritten offering, exceeds the number of shares of Common Stock which can be sold in such offering and/or that the number of shares of Common Stock proposed to be included in any such registration would adversely affect the price per share of the Common Stock to be sold in such offering, the Company shall include in such registration (i) first, the number of shares of Common Stock requested to be included therein by other holders of Common Stock, allocated among such holders in such manner as they may agree; and (ii) second, the number of shares of Common Stock requested to be included therein by the holder(s) requesting such registration and by the holders of Registrable Securities, allocated pro rata among such holders on the basis of the number of shares of Common Stock (on a fully diluted, as converted basis) and the number of Registrable Securities, as applicable, owned by all such holders or in such manner as they may otherwise agree.

 

Section 6. Events of Default.  The occurrence of any of the following shall constitute an “Event of Default” under this Note:

 

	
(a)    

	
The Company shall fail to pay any principal payment, interest or other payment required under the terms of this Note within sixty (60) days of the due date thereof;

 

	
(b)    

	
The Company 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 in full or in part, (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;

 

	
(c)     

	
Proceedings for the appointment of a receiver, trustee, liquidator or custodian of the Company 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 Company or the debts thereof under any bankruptcy, insolvency or other similar law or hereafter in effect shall be commenced and an order for relief entered or such proceeding shall not be dismissed or discharged within ninety (90) days of commencement; or

 

Section 7. Notice of Default; Cure; Remedies.  Upon an Event of Default, the Holder shall deliver written notice of the Event of Default to the Company in accordance with Section 17 hereof (a “Default Notice”).  The Company shall have the right to cure, within the thirty (30) days following the Company’s receipt of a Default Notice (the “Cure Period”), any Event of Default.  If the Company fails to cure an Event of Default within the Cure Period, then fifteen (15) days following the end of the Cure Period Holder may declare all outstanding obligations payable by the Company 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 and, in addition to the foregoing remedies, the Holder may exercise any other right, power or remedy granted to it or otherwise permitted to it by law, either by suit in equity or by action at law, or both.

 

 

  

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Section 8. Expenses.  Upon the occurrence or existence of an uncured Event of Default, and after the Cure Period has elapsed, Holder shall be entitled to recover from the Company all of Holder’s costs of collection, including without limitation, the Holder’s reasonable attorneys’ fees (whether incurred in connection with any judicial, bankruptcy, reorganization, administrative, appeals or other proceedings and whether such fees or expenses arise before proceedings are commenced or after entry of any judgment), and all other costs or expenses incurred in connection therewith.

 

Section 9. No Voting or Dividend Rights; Limitation of Liability.  Nothing contained in this Note shall be construed as conferring upon the Holder the right to vote or to consent or to receive notice as a member of the Company or any other matters or any rights whatsoever as a member of the Company.  No dividends shall be payable or accrued in respect of this Note, the interest represented hereby or the underlying securities until, and only to the extent that, the conversion rights of this Note shall have been exercised.

 

Section 10. Maximum Interest.  Notwithstanding any other provisions of this Note, any interest, fees, or charges payable by reason of the indebtedness evidenced by this Note shall not exceed the maximum permitted by law.

 

Section 11. Successors and Assigns.  The Company may not sell, transfer or otherwise dispose of this Note without the prior written consent of the Holder.  The rights and obligations of the Company and the Holder shall be binding upon and benefit the successors, assigns, heirs, administrators and transferees of the parties.

 

Section 12. Construction; Headings.  This Note shall be deemed to be jointly drafted by the Company and the Holder and shall not be construed against any person as the drafter hereof. The headings of this Note are for convenience of reference and shall not form part of, or affect the interpretation of, this Note.

 

Section 13. Severability.  Any provision of this Note that is prohibited or unenforceable in any jurisdiction shall, as to such jurisdiction, be ineffective to the extent of such prohibition or unenforceability without invalidating the remaining provisions hereof but shall be interpreted as if it were written so as to be enforceable to the maximum extent permitted by applicable law, and any such prohibition or unenforceability in any jurisdiction shall not invalidate or render unenforceable such provision in any other jurisdiction.  To the extent permitted by applicable law, the parties hereby waive any provision of law which renders any provision hereof prohibited or unenforceable in any respect.

 

Section 14. Cancellation.  After all principal, accrued interest, late charges and other amounts at any time owed on this Note have been converted or paid in full, this Note shall automatically be deemed canceled, shall be surrendered to the Company for cancellation and shall not be reissued.

 

Section 15. Amendments; Waivers.  Any term of this Note may be amended and the observance of any term of this Agreement may be waived (either generally or in a particular instance and either retroactively or prospectively), only with the written consent of the Company and the Purchaser.

 

  

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1.1 Notices.  All notices, requests, demands and other communications under this Note shall be in writing and shall be deemed to have been duly given on the date of service if served personally on the party to whom notice is to be given, on the first business day after delivery thereof to a recognized overnight delivery service for next day delivery with all charges prepaid or billed to the account of the sender, or on the third day after mailing if mailed to the party to whom notice is to be given, by first class mail, registered or certified, postage prepaid, and properly addressed as follows:

 

(a)   If to the Company:

AmpliTech Group, Inc.

35 Carlough Rd. #3

Bohemia, NY 11716

Attn:  President

 

(b)   If to the Holder:

__________________

__________________

__________________

Attention: __________

 

 

or to such other address as either party shall have specified by notice in writing given to the other party.

 

Section 16. Governing Law; Consent to Jurisdiction; Waiver of Jury Trial.  This Note shall be governed by, and construed in accordance with, the internal laws of the State of Nevada without regard to the choice of law principles thereof.  Each of the Company and the Holder irrevocably submits to the exclusive jurisdiction of the courts of the State of Nevada for the purpose of any suit, action, proceeding or judgment relating to or arising out of this Note and the transactions contemplated hereby.  Service of process in connection with any such suit, action or proceeding may be served on the Company and the Holder, as applicable, anywhere in the world by the same methods as are specified for the giving of notices under the Purchase Agreement.  Each of the Company and the Holder irrevocably consents to the jurisdiction of any such court in any such suit, action or proceeding and to the laying of venue in such court.  Each of the Company and the Holder irrevocably waives any objection to the laying of venue of any such suit, action or proceeding brought in such courts and irrevocably waives any claim that any such suit, action or proceeding brought in any such court has been brought in an inconvenient forum.  EACH OF THE COMPANY AND THE HOLDER WAIVES ANY RIGHT TO REQUEST A TRIAL BY JURY IN ANY LITIGATION WITH RESPECT TO THIS NOTE AND REPRESENTS THAT COUNSEL HAS BEEN CONSULTED SPECIFICALLY AS TO THIS WAIVER.

 

 

 

[Signature Follows On Next Page]

 

  

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IN WITNESS WHEREOF, the Company has caused this Note to be issued as of the date first written above.

 

	 	
AMPLITECH GROUP, INC.

	 
	 	 	 	 
	 	
By: 

	 	 
	 	 	
Fawad Maqbool

	 
	 	 	
President and Chief Executive Officer

	 

 

  

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Exhibit A

CONVERSION NOTICE

The undersigned holder hereby elects to exercise convert right to convert the Conversion Amount indicated below into shares of Common Stock of AmpliTech Group, Inc., a Nevada corporation, at the Conversion Rate, evidenced by Promissory Note No. _______ (the “Note”). Capitalized terms used herein and not otherwise defined shall have the respective meanings set forth in the Note.

Conversion Amount: ________________________________

Number of shares of Common Stock to be issued: ________________________________

Please issue the shares of Common Stock into which the Conversion Amount are being converted in the following name and to the following address:

 

	 	
________________________________

________________________________

________________________________

________________________________

 

	 	 
	 	 	By: (signature)   ___________________________________ 

Name: (please print) ________________________________

Title (if applicable): _________________________________

Address _________________________________________

 

________________________________________________

Dated: ___________________

 

Please mail (i) this completed form and (ii) the Note to:

AmpliTech Group, Inc.

35 Carlough Rd. #3

Bohemia, NY 11716

Attn:  Fawad Maqbool, President

 

 

 

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