Common use of Conversion Date Clause in Contracts

Conversion Date. Applicable Conversion Price: --------------------------------------- Signature: --------------------------------------- Name: --------------------------------------- Address: --------------------------------------- Amount to be converted: $ --------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- Conversion Price per share: $ --------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- Issue to: --------------------------------------- Authorized Signature: --------------------------------------- Name: --------------------------------------- Title: --------------------------------------- Phone Number: --------------------------------------- Broker DTC Participant Code: ---------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- -------------------------------------- Signature: --------------------------------------- -------------------------------------- Name: --------------------------------------- -------------------------------------- Address: --------------------------------------- -------------------------------------- Amount to be converted: $ --------------------------------------- -------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- -------------------------------------- Conversion Price per share: $ --------------------------------------- -------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- -------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- -------------------------------------- Issue to: --------------------------------------- -------------------------------------- Authorized Signature: --------------------------------------- -------------------------------------- Name: --------------------------------------- -------------------------------------- Title: --------------------------------------- -------------------------------------- Phone Number: --------------------------------------- -------------------------------------- Broker DTC Participant Code: ----------------------------------------------------------------------------- Account Number: --------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- ------------------------------------------------ Signature: --------------------------------------- ------------------------------------------------ Name: --------------------------------------- ------------------------------------------------ Address: --------------------------------------- ------------------------------------------------ Amount to be converted: $ --------------------------------------- ------------------------------------------------ Amount of Debenture unconverted: $ --------------------------------------- ------------------------------------------------ Conversion Price per share: $ --------------------------------------- ------------------------------------------------ Number of shares of Common Stock to be issued: --------------------------------------- ------------------------------------------------ Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- ------------------------------------------------ Issue to: --------------------------------------- ------------------------------------------------ Authorized Signature: --------------------------------------- ------------------------------------------------ Name: --------------------------------------- ------------------------------------------------ Title: --------------------------------------- ------------------------------------------------ Phone Number: --------------------------------------- ------------------------------------------------ Broker DTC Participant Code: --------------------------------------------------------------------------------------- Account Number:

Conversion Date. Applicable Conversion Price: --------------------------------------- -------------------------------------------------------- Signature: --------------------------------------- -------------------------------------------------------- Name: --------------------------------------- -------------------------------------------------------- Address: --------------------------------------- -------------------------------------------------------- Amount to be converted: $ --------------------------------------- -------------------------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- -------------------------------------------------------- Conversion Price per share: $ --------------------------------------- -------------------------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- -------------------------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- -------------------------------------------------------- Issue to: --------------------------------------- -------------------------------------------------------- Authorized Signature: --------------------------------------- -------------------------------------------------------- Name: --------------------------------------- -------------------------------------------------------- Title: --------------------------------------- -------------------------------------------------------- Phone Number: --------------------------------------- -------------------------------------------------------- Broker DTC Participant Code: -----------------------------------------------------------------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- -------------------------------- Signature: --------------------------------------- -------------------------------- Name: --------------------------------------- -------------------------------- Address: --------------------------------------- -------------------------------- Amount to be converted: $ --------------------------------------- $------------------------------- Amount of Debenture unconverted: $ --------------------------------------- $------------------------------- Conversion Price per share: $ --------------------------------------- $------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- -------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- -------------------------------- Issue to: --------------------------------------- -------------------------------- Authorized Signature: --------------------------------------- -------------------------------- Name: --------------------------------------- -------------------------------- Title: --------------------------------------- -------------------------------- Phone Number: --------------------------------------- -------------------------------- Broker DTC Participant Code: -----------------------------------------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- ------------------------------------- Signature: --------------------------------------- ------------------------------------- Name: --------------------------------------- ------------------------------------- Address: --------------------------------------- ------------------------------------- Amount to be converted: $ --------------------------------------- ------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- ------------------------------------- Conversion Price per share: $ --------------------------------------- ------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- ------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- ------------------------------------- Issue to: --------------------------------------- ------------------------------------- Authorized Signature: --------------------------------------- ------------------------------------- Name: --------------------------------------- ------------------------------------- Title: --------------------------------------- ------------------------------------- Phone Number: --------------------------------------- ------------------------------------- Broker DTC Participant Code: ---------------------------------------------------------------------------- Account Number: -------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- --------------------------------------------- Signature: --------------------------------------- --------------------------------------------- Name: --------------------------------------- --------------------------------------------- Address: --------------------------------------- --------------------------------------------- Amount to be converted: $ --------------------------------------- --------------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- --------------------------------------------- Conversion Price per share: $ --------------------------------------- --------------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- --------------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- --------------------------------------------- Issue to: --------------------------------------- --------------------------------------------- Authorized Signature: --------------------------------------- --------------------------------------------- Name: --------------------------------------- --------------------------------------------- Title: --------------------------------------- --------------------------------------------- Phone Number: --------------------------------------- --------------------------------------------- Broker DTC Participant Code: ------------------------------------------------------------------------------------ Account Number: ---------------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- --------------------------------------------- Signature: --------------------------------------- --------------------------------------------- Name: --------------------------------------- --------------------------------------------- Address: --------------------------------------- --------------------------------------------- Amount to be converted: $ --------------------------------------- -------------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- -------------------------------------------- Conversion Price per share: $ --------------------------------------- -------------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- --------------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- --------------------------------------------- Issue to: --------------------------------------- --------------------------------------------- Authorized Signature: --------------------------------------- --------------------------------------------- Name: --------------------------------------- --------------------------------------------- Title: --------------------------------------- --------------------------------------------- Phone Number: --------------------------------------- --------------------------------------------- Broker DTC Participant Code: ------------------------------------------------------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- ----------------------------------------- Signature: --------------------------------------- ----------------------------------------- Name: --------------------------------------- ----------------------------------------- Address: --------------------------------------- ----------------------------------------- Amount to be converted: $ --------------------------------------- ----------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- ----------------------------------------- Conversion Price per share: $ --------------------------------------- ----------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- ----------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- ----------------------------------------- Issue to: --------------------------------------- ----------------------------------------- Authorized Signature: --------------------------------------- ----------------------------------------- Name: --------------------------------------- ----------------------------------------- Title: --------------------------------------- ----------------------------------------- Phone Number: --------------------------------------- ----------------------------------------- Broker DTC Participant Code: -------------------------------------------------------------------------------- Account Number: -----------------------------------------

Conversion Date. Applicable Conversion Price: --------------------------------------- ------------------------------------------- Signature: --------------------------------------- ------------------------------------------- Name: --------------------------------------- ------------------------------------------- Address: --------------------------------------- ------------------------------------------- Amount to be converted: $ --------------------------------------- ------------------------------------------- Amount of Debenture unconverted: $ --------------------------------------- ------------------------------------------- Conversion Price per share: $ --------------------------------------- ------------------------------------------- Number of shares of Common Stock to be issued: --------------------------------------- ------------------------------------------- Please issue the shares of Common Stock in the following name and to the following address: --------------------------------------- ------------------------------------------- Issue to: --------------------------------------- ------------------------------------------- Authorized Signature: --------------------------------------- ------------------------------------------- Name: --------------------------------------- ------------------------------------------- Title: --------------------------------------- ------------------------------------------- Phone Number: --------------------------------------- ------------------------------------------- Broker DTC Participant Code: ---------------------------------------------------------------------------------- Account Number: -------------------------------------------