Document:

exhibit10-3.htm

Exhibit 10.3

CONSULTING AGREEMENT

This Consulting Agreement made and entered into effective as of the _____ day of  _____________, 2011 by and between AGH Management Corp.., a California corporation, having its principal office located at 888 Brannan Street, #153 – 155, San Francisco, CA 94103 (the "Company"), and William Mui, an individual, its principle office located at 808 Volans Lane, Foster City, CA 94404 (the "Consultant"). The Company and the Consultant are sometimes referred to herein individually as a “Party” and together as the “Parties.”

 

W I T N E SSE T H

  WHEREAS, the Company desires that Consultant perform certain Consult­ing Services for the Company; and

 

  WHEREAS, Consultant desires to perform such Consulting Ser­vices for the Company;

 

  NOW THEREFORE, in consideration of the mutual promises herein contained, the Parties do hereby agree as follows:

1.           CONSULTING TERM

Consultant will provide consulting Services for a period beginning as of signing this Agreement and terminating on December 31, 2011.  Without objection from Parties, this Agreement will automatically renew for another 6 months. Consultant should identify any subs or other contractors and ensure that they agree to comply with Section 5,6,7,8

2.           CONSULTING SERVICES

As used in this Agreement, the phrase "Consulting Services" refers to the service of advising the Company to bring one of its subsidiaries to be publicly listed on OTCBB exchange.

Consultant and the Company acknowledge that the manner, means, details and methods used by Consultant to achieve the results desired by the Company within the sole discretion and control of Consultant using the highest degree of ethics and integrity, and the highest level of skill and expertise necessary to achieve those results.

3.           COMPENSATION AND PAYMENT

In consideration of the obligations undertaken by Consultant herein and the performance thereof, the Company agrees to pay Consultant as compensation for Consulting Services provided under this Agreement the sum of fifteen thousand dollars ($15,00.00), which shall be paid as follows:

An initial Deposit of $2,000.00 shall be paid within 5 business days upon signing of this agreement. $4,000.00 shall be paid after S-1 Form has been filed to SEC. $9,000.00 shall be paid on December 15, 2011. (Final payment shall be given when both parties agrees that they had used their best effort to succeed)

  

  

  

      

	
4.

	
EXPENSES

  The Company will be responsible for travel, communications and other out-of-pocket expenses that are necessary to pro­vide Consulting Services under this Agreement. All expenses for travel will be approved in advance by the Company.  Reimbursement of Consultant’s expenses incurred hereunder will be made to Consultant within ten (10) days after submission of a written request therefor, together with appropriate vouchers and receipts.

	
5.

	
INDEPENDENT CONTRACTOR

Consultant is retained by the Company only for the purposes and to the extent set forth in this Agreement, and Consultant's relationship to the Company is that of an independent contractor.  Neither Consultant nor any officers, directors, employees, agents or contractors of Consultant who provide Consulting Services under this Agreement are agents or "employees" of the Company for any purpose.

         

	
6.

	
INDEMNIFICATION

Each of the Parties (the “Indemnifying Party”) will indemnify and save the other Party (the “Indemnified Party”) harmless from any liability or expense (including reasonable attorney's fees) that the Indemnified Party may sustain in any manner as a result of a breach of this Agreement by the Indemnifying Party and/or its gross negligence or intentional misconduct.

	
7.

	
CONFIDENTIAL INFORMATION

As used in this Agreement, "Confidential Information" includes all confi­dential or proprietary information developed or obtained by or disclosed to Consultant pur­suant to this Agreement or in connection with its Consulting Services under this Agree­ment, including, but not limited to confidential reports, financial information, trade secrets, business plans, data, formulae or any other proprietary information whether owned by the Company as of this date or hereafter developed or acquired.

Confidential Information shall not be published, disclosed, or made accessible by Consultant to any other person, firm or corporation either during or after the termination of the Consulting term.  Consultant shall restrict dissemination of all Confidential Information to its own employees, subcontractors and agents on a "need-to-know" basis.  Absent a written agreement to the contrary, all such Confidential Information remains the sole and exclusive property of the Company.  Consultant shall return all Confidential Information to the Company upon request of the Company, and upon termination of this Agreement.

Consultant acknowledges that unauthorized disclosure of such Confidential Information can have serious and irreparable impact on the Company's business; therefore, in addition to all other remedies at law, the parties agree that injunctive relief would be appropriate to prevent breach of this provision.

  

  

  

     

	
8.

	
SUCCESSORS AND ASSIGNS

Neither Consultant nor Company shall assign this Agreement or any of its respective rights or obligations under this Agreement to any other party without prior written consent of the other Party. This Agreement will be binding on and inure to the benefit of the respective legal successors and assigns of the Company and the Consultant.

	
9.

	
GUARANTIES AND WARRANTS

Company acknowledges and agrees that no guaranties or other assurances can be given that Company will receive all approvals necessary for its subsidiary publicly listing on OTCBB.  Consultant warrants that all services performed by it on behalf of Company hereunder shall be performed in an ethical and professional manner and that it will use its best efforts in that regard.

	
10.

	
GOVERNING LAW; SUBMISSION TO JURISDICTION

This Agreement referred to herein shall be governed by, and construed in accordance with, the law of the State of California. Each Party hereto hereby submits to the nonexclusive jurisdiction of the State of California for the purposes of all legal proceedings arising out of or relating to this Agreement or the transactions contemplated hereby.

	
11.

	
NOTICES

Any notice permitted or required under this Agreement shall be in writing and shall be given or made by certified or registered mail or by overnight courier addressed to the respective parties as follows:

 

	 For Company	For Consultant
	AGH Management 	808 Volans Lane
	888 Brannan Street, 	Foster City, CA 94404
	San Francisco, CA	 

 

	
12.

	
SEVERABILITY

If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall nevertheless continue in full force without being impaired or invalidated in any way.

IN WITNESS WHEREOF, Consultant and the Company have duly executed this Agreement as of the date first above written.

                                                              

	 Company: 	Consultant:
	
AGH Management, Corp

 

 

 

 

/s/ George Lam 
  

Signature

	
William Mui

 

 

 

 

 /s/ William Mui

Signatureexhibit10-4.htm

Exhibit 10.4

AMENDMENT

To

Consultant Agreement

A Consulting Agreement was made and entered into effect on March 16, 2011 between AGH Management Corp. (the “Company) and William Mui (“Consultant”). Both parties agreed to transfer this consulting agreement to L.F. George Holdings, Inc., a Delaware Corporation, on June 20, 2011. The terms and conditions under the consulting agreement between the Company and the Consultant shall remain the same between L.F. George Holdings, Inc. and the Consultant.

IN WITNESS WHEREOF, the Company and the Consultant have duly executed this amendment.

Company:                                                              Consultant:

AGH Management Corp.                                   William Mui

/s/ George Lam                                                      /s/ William Mui

Signature                                                              Signature

George Lam                                                          William Mui

____________________________              _________________________

Date                                                                       Date

LF George Holdings, Inc.

/s/ George Lam 

Signature

George Lam

____________________________

Datemhtx_ex41.htm

EXHIBIT 4.1

 

THE SECURITIES OFFERED HEREBY SHOULD BE CONSIDERED TO BE AT THE HIGH END OF THE RISK SPECTRUM AND SHOULD NOT BE PURCHASED BY ANYONE WHO CANNOT AFFORD THE LOSS OF THEIR ENTIRE INVESTMENT.

SECURITIES PURCHASE AGREEMENT

This Securities Purchase Agreement (this “Agreement”) is dated as of January __, 2014, among Manhattan Scientifics, Inc. a Delaware corporation (the “Company”), and the purchaser identified on the signature pages hereto (the “Purchaser”); and

 

WHEREAS, subject to the terms and conditions set forth in this Agreement and pursuant to Section 4(2) of the Securities Act of 1933, and/or Rule 506 promulgated thereunder, the Company desires to issue and sell to the Purchaser, and the Purchaser desires to purchase from the Company the number of shares subscribed for on page 6 hereafter, of shares of Common Stock (the “Shares”) and common stock purchase warrants (the "Warrants") on the Closing Date, as defined below.

 

NOW, THEREFORE, IN CONSIDERATION of the mutual covenants contained in this Agreement, and for other good and valuable consideration the receipt and adequacy of which are hereby acknowledged, the Company and each Purchaser agree as follows:

 

ARTICLE 1

SALE AND PURCHASE OF THE SHARES AND WARRANTS

1.1 Sale of the Shares and Warrants. Within 5 days of the execution of this Agreement (the "Closing Date"), the Purchaser shall purchase from the Company and the Company shall issue and sell to each Purchaser, the number of Shares equal to such Purchaser’s amounts set forth below such Purchaser’s signature block on the signature page hereto (the “Subscription Amount”) divided by the per share purchase price (the “Per Share Purchase Price”), which shall be $0.075, subject to adjustment for reverse and forward stock splits, stock dividends, stock combinations and other similar transactions of the Company’s common stock that occur after the date of this Agreement. For each four (4) Shares purchased, Purchaser will receive warrants (the “Warrants”) to purchase one (1) share of common stock for a period of five (5) years at an exercise price of $0.075 per share, a form of which is attached hereto as Exhibit A. The Shares and the Warrants hereinafter sometimes collectively referred to as the Securities.

 

  

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1.2 Instruments of Conveyance and Transfer.

 

(a) On the Closing Date, the Company shall deliver or cause to be delivered to the Purchaser this Agreement duly executed by the Company.

 

(b) On the Closing Date, the Purchaser shall deliver or cause to be delivered to the Company the following:

 

(i)  this Agreement duly executed by such Purchasers;

 

(ii)  a Warrant duly executed by the Company;

 

(iii)  a copy of the completed Accredited Investor Questionnaire, a copy of which is attached hereto as Exhibit B.

 

1.3 Consideration for the Shares. The Purchaser’s total purchase price for the Shares and the Warrants is the Subscription Amount.

 

ARTICLE 2

REPRESENTATIONS AND COVENANTS OF SELLER AND PURCHASER

 

2.1 The Company hereby represents and warrants that:

(a) The Securities issued hereunder have been duly authorized by the appropriate corporate action of the Company.

(b) The Company shall transfer title, in and to the Securities to the Purchaser free and clear of all liens, security interests, pledges, encumbrances, charges, restrictions, demands and claims, of any kind and nature whatsoever, whether direct or indirect or contingent.

(c) The certificate representing the Shares and the shares of common stock underlying the Warrants which will be issued to the Purchaser shall be subject to no liens, security interests, pledges, encumbrances, charges, restrictions, demands or claims in any other party whatsoever, except as set forth in the legend on the certificate, which legend shall provide as follows:

THE SHARES (OR OTHER SECURITIES) REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933. THE SHARES MAY NOT BE SOLD OR TRANSFERRED IN THE ABSENCE OF SUCH REGISTRATION OR AN OPINION OF COUNSEL THAT AN EXEMPTION FROM REGISTRATION UNDER SUCH ACT IS AVAILABLE.

 

  

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(d) No Brokers. Except for the Consulting Agreement entered between the Company and Govdesk, LLC ("Govdesk"), pursuant to which Govdesk shall receive from the Company a cash fee of six percent (6%) of any investment received from an investor introduced to the Company by Govdesk as well as common stock purchase warrants to acquire 4,562,500 shares of common stock for a period of five (5) years at an exercise price of $0.075 per share, the Company has taken no action which would give rise to any claim by any person for brokerage commissions, transaction fees or similar payments relating to this Agreement or the transactions contemplated hereby.

(e) Purchaser acknowledges and agrees that the Company makes no other representations or warranties with respect to the Shares or the Company.

2.2 Purchaser represents and warrants to the Company as follows:

(a) Purchaser has adequate means of providing for current needs and contingencies, has no need for liquidity in the investment, and is able to bear the economic risk of an investment in the Securities offered by the Company of the size contemplated. Purchaser represents that Purchaser is able to bear the economic risk of the investment and at the present time could afford a complete loss of such investment. Purchaser has had a full opportunity to inspect the books and records of the Company and to make any and all inquiries of the Company officers and directors regarding the Company and its business as Purchaser has deemed appropriate.

(b) Purchaser is an “Accredited Investor” as defined in Regulation D of the Securities Act and Purchaser, either alone or with Purchaser’s professional advisers who are unaffiliated with, have no equity interest in and are not compensated by the Company or any affiliate or selling agent of the Company, directly or indirectly, has sufficient knowledge and experience in financial and business matters that the Purchaser is capable of evaluating the merits and risks of an investment in the Securities offered by the Company and of making an informed investment decision with respect thereto and has the capacity to protect Purchaser’s own interests in connection with Purchaser’s proposed investment in the Securities.

(c) Purchaser acknowledges that the Securities including the shares of common stock underlying the Warrants will initially be “restricted securities” (as such term is defined in Rule 144 (“Rule 144"), promulgated under the Securities Act of 1933, as amended (the “Securities Act”), that the Securities will include the restrictive legend set forth above, and, except as otherwise set forth in this Agreement, that the Securities cannot be sold unless registered with the United States Securities and Exchange Commission (“SEC”) and qualified by appropriate state securities regulators, or otherwise complies with an exemption from such registration and qualification (including, without limitation, compliance with Rule 144).

(d) The Purchaser has carefully read the Form 10-K Annual Report for the year ended December 31, 2012, the Form 10-Q Quarterly Report for the quarter ended September 30, 2013 and all other reports filed with the SEC (the “Reports”) as well as all other filings made by the Company with the SEC, and the related risk factors (the “Risk Factors”), which are contained in the Reports. The undersigned has been given the opportunity to ask questions of, and receive answers from, the Company concerning the terms and conditions of this offering, the Reports and the Risk Factors and to obtain such additional information, to the extent the Company possesses such information or can acquire it without unreasonable effort or expense, necessary to verify the accuracy of same as the undersigned reasonably desires in order to evaluate the investment. The Purchaser understands the Reports and the associated Risk Factors, and the undersigned has had the opportunity to discuss any questions regarding any of the disclosure in the Reports and the associated Risk Factors with his counsel or other advisor. Notwithstanding the foregoing, the only information upon which the undersigned has relied is that set forth in the Reports and the associated Risk Factors. The undersigned has received no representations or warranties from the Company, its employees, agents or attorneys, in making this investment decision other than as set forth in the Reports and the associated Risk Factors. The undersigned does not desire to receive any further information.

 

  

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(e) The Purchaser is aware that the purchase of the Securities is a speculative investment involving a high degree of risk, that there is no guarantee that the undersigned will realize any gain from this investment, and that the undersigned could lose the total amount of this investment. The undersigned acknowledges that the proceeds will be utilized for working capital.

 

(f) The Purchaser understands that no federal or state agency has made any finding or determination regarding the fairness of the Securities for investment, or any recommendation or endorsement of the Securities.

 

(g) The Purchaser represents that the Purchaser is not a broker, a broker dealer or an affiliate of a broker dealer.

 

ARTICLE 3

MISCELLANEOUS

 

3.1 Entire Agreement. This Agreement sets forth the entire agreement and understanding of the parties hereto with respect to the transactions contemplated hereby, and supersedes all prior agreements, arrangements and understandings related to the subject matter hereof. No understanding, promise, inducement, statement of intention, representation, warranty, covenant or condition, written or oral, express or implied, whether by statute or otherwise, has been made by any party hereto which is not embodied in this Agreement or the written statements, certificates, or other documents delivered pursuant hereto or in connection with the transactions contemplated hereby, and no party hereto shall be bound by or liable for any alleged understanding, promise, inducement, statement, representation, warranty, covenant or condition not so set forth.

 

3.2 Notices. Any notice, request, instruction, or other document required by the terms of this Agreement, or deemed by any of the parties hereto to be desirable, to be given to any other party hereto shall be in writing and shall be given by facsimile, personal delivery, overnight delivery, or mailed by registered or certified mail, postage prepaid, with return receipt requested. If notice is given by facsimile, personal delivery, or overnight delivery in accordance with the provisions of this Section, said notice shall be conclusively deemed given at the time of such delivery. If notice is given by mail in accordance with the provisions of this Section, such notice shall be conclusively deemed given seven days after deposit thereof in the United States mail.

 

3.3 Waiver and Amendment. Any term, provision, covenant, representation, warranty or condition of this Agreement may be waived, but only by a written instrument signed by the party entitled to the benefits thereof. The failure or delay of any party at any time or times to require performance of any provision hereof or to exercise its rights with respect to any provision hereof shall in no manner operate as a waiver of or affect such party's right at a later time to enforce the same. No waiver by any party of any condition, or of the breach of any term, provision, covenant, representation or warranty contained in this Agreement, in any one or more instances, shall be deemed to be or construed as a further or continuing waiver of any such condition or breach or waiver of any other condition or of the breach of any other term, provision, covenant, representation or warranty. No modification or amendment of this Agreement shall be valid and binding unless it be in writing and signed by all parties hereto.

 

3.4 Choice of Law. This Agreement and the rights of the parties hereunder shall be governed by and construed in accordance with the laws of the State of New York including all matters of construction, validity, performance, and enforcement and without giving effect to the principles of conflict of laws.

 

  

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3.5 Jurisdiction. The parties submit to the jurisdiction of the Courts of the County of New York, State of New York or a Federal Court empanelled in the State of New York for the resolution of all legal disputes arising under the terms of this Agreement, including, but not limited to, enforcement of any arbitration award.

 

3.6 Counterparts. This Agreement may be executed in two or more counterparts, including, without limitation, by facsimile transmission, all of which counterparts shall be considered one and the same agreement and shall become effective when counterparts have been signed by each party and delivered to the other party. In the event any signature page is delivered by facsimile transmission, the party using such means of delivery shall cause additional original executed signature pages to be delivered to the other parties as soon as practicable thereafter.

 

3.7 Attorneys' Fees. Except as otherwise provided herein, if a dispute should arise between the parties including, but not limited to arbitration, the prevailing party shall be reimbursed by the non-prevailing party for all reasonable expenses incurred in resolving such dispute, including reasonable attorneys' fees exclusive of such amount of attorneys' fees as shall be a premium for result or for risk of loss under a contingency fee arrangement.

 

3.8 Taxes. Any income taxes required to be paid in connection with the payments due hereunder, shall be borne by the party required to make such payment. Any withholding taxes in the nature of a tax on income shall be deducted from payments due, and the party required to withhold such tax shall furnish to the party receiving such payment all documentation necessary to prove the proper amount to withhold of such taxes and to prove payment to the tax authority of such required withholding.

 

[SIGNATURE PAGE FOLLOWS]

 

  

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IN WITNESS WHEREOF, the parties hereto have executed this Stock Purchase Agreement, as of the date first written hereinabove.

 

	MANHATTAN SCIENTIFICS, INC. 	 	 	
Address for Notice:

	 
	 	 	 	 	 	 
	By:	 	 	 	

405 Lexington Avenue, 32nd Floor

	 
	Name:	Emmanuel Tsoupanarias	 	 	
New York, New York, 10174

	 
	Title	Chief Executive Officer	 	 	 	 

 

 

[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK SIGNATURE PAGES FOR PURCHASER FOLLOWS]

 

  

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[PURCHASER SIGNATURE PAGES TO SECURITIES PURCHASE AGREEMENT]

 

IN WITNESS WHEREOF, the undersigned have caused this Securities Purchase Agreement to be duly executed by their respective authorized signatories as of the date first indicated above.

 

Total Subscription Amount: $1,125,000 ($0.075 per share)

 

Shares 15,000,000 (determined by dividing the above subscription amount by $0.075)

Warrants 3,750,000 (determined by multiplying the number of Shares by 4)

 

Tax Payer Identification Number (or Social Security or EIN number): _____________________________

 

Name of Purchaser: Drake Private Investments, LLC

 

Signature of Authorized Signatory of Purchaser: __________________________________

 

Name of Authorized Signatory:_________________________________________________

 

Title of Authorized Signatory:__________________________________________________

 

Email Address of Purchaser:___________________________________________________

 

Facsimile of Purchaser:_______________________________________________________

 

Address for Notice of Purchaser:

__________________________________________________________________________

 

__________________________________________________________________________

 

Address for Delivery of Securities for Purchaser (if not same as above):

 

__________________________________________________________________________

 

__________________________________________________________________________

 

  

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EXHIBIT B

 

ACCREDITED INVESTOR QUESTIONNAIRE

 

The Purchaser warrants and represents to the Company that it qualifies as an “accredited investor,” as such term is defined in Rule 501(a) of Regulation D under the Securities Act of 1933, as amended (the “Securities Act”), by virtue of the fact that the Purchaser meets the following criteria at the time of the sale of the Securities to the Purchaser (Purchaser must initial the applicable categories below):

 

I. ACCREDITED INVESTOR STATUS

 

A. Individual Investors: (Initial one or more of the following statements)

 

1. ____ I certify that I am an accredited investor because I have had individual income (exclusive of any income earned by my spouse) of more than $200,000 in each of the two most recent calendar years and I reasonably expect to have an individual income in excess of $200,000 for the current year.

 

2. ____ I certify that I am an accredited investor because I have had joint income with my spouse in excess of $300,000 in each of the two most recent calendar years and I reasonably expect to have joint income with my spouse in excess of $300,000 for the current year.

 

3. ____ I certify that I am an accredited investor because I have an individual net worth, or my spouse and I have a joint net worth, in excess of $1,000,000 which excludes the value of your primary residence.

 

4. ____ I certify that I am an accredited investor because I am a director, executive officer, or general partner of the issuer of the securities being offered or sold, or any director, executive officer, or general partner of a general partner of that issuer.

 

B. Partnerships, Corporations, Trusts or Other Entities: (Initial one of the following statements)

 

1. The undersigned hereby certifies that it is an accredited investor because it is:

 

a. ______ any corporation, partnership, or Massachusetts or similar business trust, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000;

 

b. ______ a trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a person who has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of an investment in the securities offered as described in Rule 506(b)(2)(ii) under the Securities Act;

 

  

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c. ______ an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, whose investment decisions are made by a plan fiduciary, as defined in Section 3 (21) of such act, which is either a bank, savings and loan association, an insurance company or registered investment adviser;

 

d. ______ a self-directed employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, with investment decisions made solely by persons that are accredited investors;

 

e. ______ an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 with total assets in excess of $5,000,000;

 

f. ______ any plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, with total assets in excess of $5,000,000;

 

g. ______ an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000;

 

h. ______ a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940;

 

i. ______ any bank as defined in Section 3(a)(2) of the Securities Act or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act whether acting in its individual or fiduciary capacity;

 

j. ______ any broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended;

 

k. ______ any insurance company as defined in Section 2(a)(13) of the Securities Act;

 

l. ______ any investment company registered under the Investment Company Act of 1940 or a business development company as defined in Section 2(a)(48) of the Investment Company Act of 1940;

 

m. ______ any Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958; or

 

2. ____ The undersigned hereby certifies that it is an accredited investor because it is an entity in which each of the equity owners qualifies as an accredited investor under items A(1), (2) or (3) or item B(1) above.

 

[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]

 

  

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Please indicate whether Purchaser is an INDIVIDUAL, or if purchased as JOINT TENANTS, as TENANTS IN COMMON, or as COMMUNITY PROPERTY:

 

Date: _____________, 2014

 

	___________________________________	 	___________________________________	 
	
Purchaser(s) Purchaser(s)

	 	 	 
	 	 	 	 
	___________________________________	 	___________________________________	 
	
Print Name(s) Print Name(s)

	 	 	 
	 	 	 	 
	___________________________________	 	___________________________________	 
	
Print Title Print Title

	 	 	 
	 	 	 	 
	___________________________________	 	___________________________________	 
	Signature(s)	 	Signature(s)	 
	 	 	 	 
	___________________________________	 	 	 
	 	 	 	 
	___________________________________	 	 	 
	
Address

	 	 	 
	 	 	 	 

 

 

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