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