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: -------------------------------------- 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: -------------------------------------- ------------------------------------- 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: -------------------------------------- ------------------------------------------- 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: -------------------------------------- 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: -------------------------------------- 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: -------------------------------------------------------------------------------