2013 Artist Rider

The following provisions shall be deemed incorporated in and part of the agreement for the performance of Leslie West and Friends, on ______at ______in ______The purpose of this rider is to guarantee the PURCHASER, the ARTIST, and the audience the best performance situation possible.

1. No Deviations or eliminations from this rider shall be made without prior approval of the ARTIST’s management. Deviations or eliminations will only delay the successful execution of this contract.

2. All technical inquiries should be directed to: Mark Webber 914-325-2547 Mike Goldberg 973-493-5776

3. All press related inquires should be directed to: Steve Karas 917-420-0728 Chuck Bliziotis /Mascot Label Group 212-620-5909 917-940-2966

Survival Management, Inc. Bob Ringe: President 30765 Pacific Coast Highway Suite 325 Malibu, CA 90265 310/317-9223 Ph 310/317-9225 F

Hospitality and Rider Questions Contact Jenni West 201-496-3452 [email protected]

1. BILLING A. Billing in all advertising & publicity is to read “Leslie West of Mountain”

B. ARTIST shall receive 100 percent EXCLUSIVE HEADLINE BILLING in all advertising, marquees, displays, programs, and any and all publicity. Any deviation from this billing is acceptable only with the prior written consent of Survival Management, Inc...

2. PAYMENTS Purchaser shall make payments as follows: Provided ARTIST is ready, willing, and able to perform, BUYER agrees to compensate ARTIST in accordance with the terms hereof, regardless of inclement weather, Act of God, fire, accident, riot, strike, or any other event similar or dissimilar to the foregoing events which would prevent or interfere with the presentation of the performance hereunder.

A. All guaranteed payments shall be made in the form of cash, cashier’s check, or money order.

B. Any and all overages shall be in the form of cash.

C. A DEPOSIT in the amount of 50 percent (50%) of the ARTIST’S guaranteed engagement fee (exclusive of any percentage of the box receipts) shall be paid by the BUYER to the booking agent concurrent with execution and/or delivery of the contract by the BUYER. Said deposit shall be held in trust by the booking agent and paid to the ARTIST or ARTIST’S representative prior to performance of the engagement or upon forfeiture by the BUYER because of any material failure of consideration and/or material breach of contract by the BUYER.

D. THE BALANCE of ARTIST’S engagement fee, as well as any and all percentages of box office receipts due ARTIST under this contract, including applicable payments listed under paragraph B-3, shall be paid to the ARTIST or ARTIST’S representative at the time of the engagement prior to ARTIST’S performance.

E. Purchaser agrees to pay: 1. In states where a taxing authority intends to deduct any portion of (ARTIST) guarantee, including Union Fees, it shall be the buyer’s responsibility to pay the amount due in addition to (ARTIST) contracted fee. This additional cost should be treated as a show expense.

2. It is expressly understood that it shall be buyer’s total responsibility to provide any and all necessary liability insurance pertaining to the above described performance.

3. BUYER agrees that ARTIST shall have the right to cancel this agreement without liability upon notice to BUYER 30 days prior to the date of the first performance

F. The contract price for this engagement has been negotiated based on information given to the ARTIST through his agent and management by the contracting party whose name appears on the face of the attached contract. This engagement is subject to immediate cancellation and forfeiture of buyer’s deposit at ARTIST’S discretion if the capacity and/or ticket prices increase after the contract is issued unless agreed to in writing by both parties to this contract.

G. PAYMENTS FOR UNAUTHORIZED CHANGES: BUYER shall pay to ARTIST’S representative ARTIST’S percentage of box office receipts based on the ticket price and percentage clause stated on the attached contract, even if tickets have been sold at less than the stated contract price. Similarly, if BUYER sells tickets to ARTIST’S performance at a price greater than the stated contractual ticket price, BUYER will pay to ARTIST’S representative One Hundred (100%) percent of the increased amount on each and every ticket sold. (Example: Stated contract ticket price: $8.00 – actual price of ticket sold $10.00; therefore, amount paid to ARTIST, in addition to all other contractual payments, is $2.00 for every ticket sold. In the event that BUYER sells a number of tickets greater than the seating capacity stated on the attached contract, BUYER shall pay to ARTIST’S representative One Hundred (100%) percent of the ticket price for every ticket sold beyond the stated seating capacity. (Example: stated capacity: 1,000; number of tickets sold 1100; ticket price $10.00; amount paid to ARTIST, in addition to other contractual payments is: $1,000.00).

In the event the capacity of the venue is reduced for any reason without ARTIST’S prior written consent and all available tickets are sold, ARTIST shall be paid based on the stated capacity on the face of the attached contract.

3. TICKET MANIFEST

A. PURCHASER shall supply a ticket manifest showing the number, color, and price of all tickets for the performance upon signing of this contract. All tickets must be consecutively numbered, and in the event of more than one show/performance, the tickets must be contrasting colors for each show. Said ticket manifest must be printed by a bonded printer and must also be notarized. When available, turnstiles will be used on the doors of admittance to ensure an accurate check of the manifest.

B. The PURCHASER is liable for any and all counterfeit tickets and under no circumstances will the ARTIST assume a loss on any such tickets.

C. PURCHASER shall limit all complimentary tickets to 1% (one percent) of the total manifest. No complimentary tickets will be allowed to guest artists or groups without prior authorization by the ARTIST’S Road Manager.

D. COMPLIMENTARY TICKETS for “good” seats or in the case of “no seating,” “best area” in an amount not to exceed twenty six (26) will be provided for ARTIST’S use for each performance. Artist reserves the right to additional tickets (up to50) for guest seating in New York City, Ontario and LA, performances.

4. PERFORMANCE

A. ARTISTIC CONTROL of ARTIST’S performance SHALL BE SOLELY vested in ARTIST with regard to material, accompaniment, wardrobe, lighting, sound, staging, etc.

B. THE DURATION of ARTIST’S performance will be approximately 75 minutes unless otherwise agreed in writing, and ARTIST shall be permitted to perform for a greater or lesser duration (not less than 60 minutes no more than 90 minutes) at the ARTIST’S option without interference of any kind from BUYER or anyone representing BUYER. Under no condition(s) will a situation be permitted by the BUYER whereby a supporting act’s length of performance, local curfew, building policy, etc., would cause the ARTIST to have to cut or alter ARTIST’S show.

C. NO SUPPORTING ACT, announcer, master of ceremonies, performing artist or group(s) of artists shall appear or perform as part of the engagement without prior approval of ARTIST. Please advance with Bob Ringe for approval at numbers listed on the first page.

D. Under no conditions shall supporting act consist of more than four (4) musicians. Groups containing keyboards and/or drum kits containing more than one bass drum are unacceptable because of stage and time considerations. Furthermore, no supporting act shall be permitted to use any smoke and/or fog generating devices of any kind during this engagement. Also, on stage access during supporting act’s performance is strictly limited to supporting act’s band members and its crew. No photographers, cameramen, etc., will be permitted on stage without prior authorization.

E. The number of supporting acts is limited to one (1) unless otherwise agreed to by ARTIST.

F. Under no circumstances will the supporting act(s) be able to use ANY of Leslie West’s and/or Band’s stage equipment: monitor, console, and EQ’s. We will NOT share channels with other acts.

G. Supporting Acts are asked to present set list to ARTIST’S road manager prior to performance to insure no duplication of material is performed.

5. ANCILLARY RIGHTS

A. The PURCHASER will make arrangements for all lights not specifically required by local safety ordinances to be turned off during performance. This especially applies to clocks, scoreboards, advertising billboards, and concession lights in the hall. All doorways to lighted hallways will be curtained.

B. The PURCHASER agrees that he will not commit ARTIST or any member thereof to any personal appearances, interviews, or any type of promotional appearance without first obtaining artist’s permission through Artist Management.

C. No portion of the engagement, including without limitation the performance of the ARTIST, or any activity of the PURCHASER or their respective employees, undertaken in connection herewith, may be recorded on film, video tape or otherwise, or may be reproduced photographically or by any sight or sound device by the PURCHASER, or any other person. The ARTIST expressly reserves such rights for itself and its licensee(s) and designee(s), and the PURCHASER shall render any cooperation required by the ARTIST for such purpose, including without limitation, affording the designee(s) or licensee(s) of the ARTIST access to the engagement and the right of free and uninhibited movement in and above the place of engagement

D. The use of electronic devices included, but not limited to, cell phones, pagers, cameras and computers are strictly prohibited in dressing room and stage areas without prior written consent of Artist or Artist’s representative. The ARTIST expressly reserves such rights for itself and its licensee(s) and designee(s), and the PURCHASER shall render any cooperation required by the ARTIST for such purpose, including without limitation, affording the designee(s) or licensee(s) of the ARTIST access to the engagement and the right of free and uninhibited movement in and above the place of engagement.

6. WARRANTIES

A. Purchaser agrees that the attached contract is the only valid instrument for this engagement. No other contracts for ARTIST’S services will be valid under any conditions whatsoever. If any person attempts or claims to bind ARTIST to any contract other than one issued by Entourage Talent Associates, LTD, this engagement is subject to immediate cancellation and purchaser is liable for the full contract price at the ARTIST’S discretion in addition to any other rights that the ARTIST may have.

B. You represent and warrant that you have the right, power and authority to enter into this Agreement, to grant the rights granted hereunder and to perform all the services to be performed hereunder. You hereby agree to and do hereby indemnify, save and hold Big Rack, LLC and Leslie West, harmless from any and all damages, liabilities, costs and expenses, including legal costs and attorneys’ fees, arising out of or connected with any claim, demand or action by a third party which is inconsistent with any of the warranties, representations or covenants made by you in the Agreement and you agree to reimburse Big Rack, LLC. on demand for any payment made by Big Rack, LLC at any time with respect to any such damage, liability, cost or expense to which the foregoing indemnity applies.

C. In the event that an action is brought to enforce any of the provisions hereof, the prevailing party shall be entitled to receive all of his or its costs in connection therewith, including costs of litigation and reasonable attorneys’ fees.

7. TRANSPORTATION /HOTELS (Please initial that you have reviewed this in detail) A. PURCHASER shall provide, at no expense to the ARTIST, transportation from the hotel to the venue and return. For type of transportation and schedule contact Tour Manager at numbers on first page. If manager is unreachable, coordinate through Jenni West at 201/496-3452. Please note that Leslie requires a wheelchair accessible vehicle for transport****

B. FLY-IN DATES ONLY: PURCHASER shall provide, at no expense to the ARTIST, transportation beginning with a pick up at the airport to hotel, to and from concert, and return to the airport. Transport MUST BE WHEELCHAIR LIFT or RAMP equipped! Please coordinate through tour manager, or if manager is unreachable, through Jenni West at 201/496- 3452.

C. Purchaser must make available within 20 miles to venue a hotel with Handicap Accessible room. Room must have shower seat, handrails for toilet and be ADA compliant. Please note that major chain hotels are usually all ADA compliant. For a list of ADA compliant hotels in your area you can go to www.adacomplianthotels.com

D. If air travel is included in the contract, please note that Leslie requires two first or business class tickets in the first or last row of the full size plane. We highly recommend that you contact our Travel agent to assist you in this planning as some airports/ airlines may travel into gate that is not handicap accessible. Rerouting may be necessary to assure that no stairs are needed and the aircraft is ADA compliant/accessible. Travel Agent is Sabre Travel 201-405-1999. If available ask for Jeanette, as she is familiar with Leslie’s travel requirements.

8. SOUVENIR AND MERCHANDISE SALES ARTIST’S agent shall have the sole and exclusive right to sell the ARTIST’S merchandise / souvenirs in connection with and at the place of engagement, and the receipts there from shall belong exclusively to the ARTIST agent subject to house policy.

9. STAGE MANAGER PURCHASER’S authorized representative will be completely responsible for stage hands; rider requirements; unloading of trucks; and any other technical difficulties occurring before, during, and after the performance.

10. TECHNICAL REQUIREMENTS

A. Stage, Sound Wings, and Mixing Platform:

1. Stage: Minimum of 25 feet wide by 15 feet deep with an elevation of 3’ or greater if crowd size dictates better view of stage. There must be a height clearance of 25’ from the stage deck to the roof. Stage surface must be smooth, sturdy, and level. All outdoor stages must have roof. Stage must be accessible by wheelchair with a ramp no less than 30 inches wide with appropriate pitch (9.50) as defined in ADA guidelines.

2. A riser capable of holding 2000 pounds and no less that 8’ X 8’ and 18” tall with adjoining ramp with a minimum of 30 inch width securely fastened to the stage and riser must be supplied for Leslie during sound check and show time, if stage is at audience level. Riser will be equipped with a microphone stand and appropriate space for pedals and effects as needed. Any modifications from this request must be specifically approved by Leslie and/or his Tour manager and compliant with ADA guidelines.

3. Drum riser is also required at no less than 8’ X 8’ and 18” tall with drum mat covering entire area.

4. Sound Wings: Sound wings must be large enough to place all speaker cabinets on. No speakers shall infringe on the stage itself. Contact production company supplying sound for dimensions. Sound wings must be the same height as and exactly aligned to the down stage edge.

5. Mixing Platform: The mixing platform shall be 16 feet wide, 8 feet deep and 2 feet high. It should be located 40-60 feet in front of center stage. Mixing Platform MUST be covered for outdoor shows.

6. Monitor Mix System: The monitor position should always be located downstage left. Monitor position MUST be covered for outdoor shows.

7. In the event it is necessary for PURCHASER to have any other act, their crew and equipment on the stage during the time assigned to ARTIST, the PURCHASER agrees that they will not occupy the space allocated to ARTIST and their presence will be concealed from the audience by means of curtains, drops or screens.

B. Power Requirements

1. Monitor system requirements: (3) separate 110 volt 30 amp circuits and located downstage left.

2. Backline power requirements: (6) 20 amp 110 circuits with Quad boxes for band gear. Single 20 amp breakers minimum. (see stage plot)

3. FOH power requirements: (3) separate 110 volt 30 amps circuits with quad boxes located at the mixing platform at center stage.

C. Sound and Lights

1. PURCHASER agrees to provide at his sole expense a P.A. system for the front of house that is acceptable to and meets the enclosed requirements of the ARTIST including a monitor engineer and FOH engineer. These engineers shall be here for set-up, break-down and the duration of the show. . 2. PURCHASER agrees to provide at his sole expense a lighting system that is acceptable to and meet the requirements of the ARTIST including a lighting engineer and crew required for set-up, breakdown and operation for the duration of the show.

3. It is specifically agreed and understood that the representative of the ARTIST shall have sole and absolute authority in mixing and controlling all sound and lighting equipment while ARTIST is performing.

4. All lighting and sound personnel must be available for sound check and lighting review at least three and a half hours prior to the doors opening.

5. A minimum of three physically able and sober stage hands must be available for off load, set up, strip down and load out of equipment. Purchaser agrees to comply to all local and state laws for use of union or workers.

D. Backline

1. Leslie’s Guitar backline: a. (2) Blackstar Series 100 heads b. (2) Blackstar 4x12 cabinets c. 4 instrument cables (2) 25 foot (2) fifty foot d. 4 guitar stands

2. Bass backline requirement: a. (1) Eden 4x10 cabinet b. (1) Eden 115 Cabinet c. (1) Eden Amp head d. 4 instrument cables (2) 25 foot (2) 50 foot e. 2 guitar stands

3. Drums Ludwig drums or equivalent (14 X 26 or 14 X24) bass drum 9 X 13 Tom 16 X 16 Tom 16 X 18 Tom 6.5 X 14 Ludwig Black Beauty snare Paiste cymbals 24” Paiste 2002 ride 15” Paiste 2002 sound edge Hi Hats Paiste 2002 17”, 18”, 20” crashes Paiste 2002 10” splash Paiste 2002 18” China Paiste 2002 20” China HARDWARE: 2 snare stands 1 hi hat stand Axis double bass pedal Throne 4 boom cymbal stands 3 straight cymbal stands Drum rug Fan

TECHNICAL SPECIFICATIONS Revised 03/01/2012

11. PA SYSTEM A. The ARTIST’S F.O.H. Engineer will have full access to all P.A. CONTROLS…NO HIDDEN COMPRESSION OR LIMITING!

B. The P.A. SYTEM will consist of all current and high quality (See Below) components, and all will be in good working order.

C. CLARITY AND HEADROOM is our main objective. The ARTIST is a High Energy Rock Band which means we are LOUD…STAGE VOLUME and HOUSE VOLUME!

4. The P.A. SYSTEM is expected to Reproduce and Maintain 30HZ to 18KHZ at 115db Minimum SPL continuous at the F.O.H. mix position at all times with NO distortion!

F.O.H. CONSOLE REQUIREMENTS A. The F.O.H. Console* will be a minimum of 40 Channels with 8 VCA groups and a minimum of 8 AUX sends.

Acceptable FOH Consoles are any of the following: Midas- H 3000, Midas XL-4, Midas XL-3, Soundcraft- Series FIVE, MH 4 or MH 3 Yamaha- PM5000, Yamaha PM 4000,

*Any other consoles other than the above must be approved by ARTIST’S Representative!

SPEAKER ENCLOSURES

ALL Speakers must be able to obtain the above mentioned specifications for SPL without exception! Artist’s sound engineer and /or tour manager to determine adequate number of boxes to ensure proper coverage of all audience areas.

****LINE ARRAY SYSTEMS are the FIRST PREFFERED.

Acceptable Speaker Enclosures are: L’ACOUSTICS V-DOSC MEYER EAW EV JBL MARTIN

*ANY OTHER SPEAKER ENCLOSURE SYSTEMS MUST BE APPROVED BY ARTIST’S Representative!

OUTBOARD PROCESSING / EFFECTS / DRIVE All Processing will coincide with the ARTIST’S Input List / Stage Plot provided and will be of superior quality.

PROCESSING as follows: System Drive: XTA/BSS or EAW or KT or System approved processor ***Controllers located at FOH mix position, all fully accessible by Artist’s engineer:

8 NOISE GATES – Drawmer, Klark-Tek, DBX 8 COMPRESSOR / LIMITERS –DBX 1YAMAHA SPX-990 MULTI-EFFECTS 2 Yamaha SPX 2000, 1000, 900, 90, 90II 1 Digital Delay Unit: TC 2290 or Lexacon PCM 41/42 1 Stereo graphic EQ on the LR of the main system: Klark Teknik DN-360 or equivalent 1 CD Player wired for playback

12. MONITOR SYSTEM SPECIFICATIONS

MONITORS:

 40 x 8 Monitor mixing board [Yamaha or Soundcraft or Midas]  Power amps: Crown Macrotech, Itech, or QSC Powerlite  6 Wedges with 2 – 12” and 1 – 1” horn in each  2 Stereo Tri Amped Side fills with 2 x 15”, 2 x 10” or 12”, 1 x 2” horn in each.  1 Tri Amped Drum box with 2-15”, 2-10” or 12”, 1 x 2” horn.  6 – 31 Band EQ’s: Klark Teknik DN-360 or BSS or Ashley GQX 40 channels, 6 mixes

Mix 1 – Center/Stage Left [2 Wedges],

Mix 2 – Bass Stage Right [2 Wedges],

Mix 3 – Drum Fill Mix 4 – Stage Right Fill***

Mix 5 – Stage Left Fill***

Mix 6 - Spare

***MAKE SURE YOU HAVE SIDE FILLS AS THE RIDER STATES

13. SECURITY A. Stage – Two security persons should be made available and positioned at the bottom of the stage steps/ramp. Please note that security must be able to assist Leslie to and from the stage in a wheelchair.

B. Dressing Rooms – Two security men should be made available and positioned at the entrance of the dressing room area. If handicap restroom is not available in dressing room, purchaser must supply security to and from restroom as needed.

C. If venue is farther than 100 yards from dressing room, purchaser must supply and Security escort to stage area. Please note that security must be able to assist Leslie to and from stage on a wheelchair.

14. DRESSING ROOMS

PURCHASER will furnish Dressing Rooms: Two lockable dressing rooms for the sole use of ARTIST and crew. Keys to be given upon arrival of the Artist Representative. If rooms are not lockable, guards must be provided to ensure the safety of the bands belongings. Each dressing room shall contain a full length mirror, 10 bath size towels, A.C. power receptacle, comfortable chairs with arms, and be well lit. Dressing rooms must be properly heated/cooled, contain one large table, and be accessible to the stage without passing through the audience. There must be a sink with hot and cold running water in at least one of the rooms. If the dressing rooms are not acceptable and ADA compliant to the Artist, Promoter shall provide and pay for one double room in close proximity to the venue.

***DRESSING ROOM and RESTROOM must be wheelchair accessible with a ramp width of 36 inches or greater as specified in ADA requirements. Restroom must have 60 inches of clear floor for turning radius. If safety rails are not secured to the wall in accordance to ADA specifications, prior arrangements must be made with tour manger or Leslie prior to show. All doorways must meet ADA compliance with a width of 36 inches for clearance of wheelchair into rooms and on to stage.

Any deviation from these guidelines must be approved by Leslie and/or Tour Manager. In the event that these requirements can NOT be met; PURCHASER must supply hotel room within 10 miles of the venue that is ADA compliant.

HOSPITALITY RIDER

15. FOOD, MEALS, AND REFRESHMENTS FOR THE BAND AND CREW

No one other than ARTIST or crew may touch any of the food or refreshments until ARTIST and ARTIST’s crew have finished!!!

CATERING

 Hot meals for ______people to be served at least two hours before show time. If meals are not available, a buyout of $30.00 per person shall be substituted. Please offer one vegetarian choice if possible. NO SHELLFISH! Please take in consideration that Leslie is diabetic. Low carb and low sugar alternatives would be appreciated.

 Important: Take-Out Chinese food, McDonalds, Pizza, Burger King, or any type of fast food facility, does not constitute a hot meal.

BACKSTAGE CATERING

 1 Deli tray to include Roast beef, Ham, Turkey, Salami [no processed meats] & three cheeses, BREAD: white, rye, and Whole Wheat bread, light mayo, mustard, napkins, and table servings for ______.

 1 assorted fruit platter [uncut]

 1 assorted vegetable platter with non-fat dip.

 2 Boxes of SUGAR FREE cookies assorted flavors

 1 large bag of chips (preferably Baked Doritos or Baked Lays)

 Diet Fanta orange, Diet Slice orange, Diet Sierra Mist or Diet Rootbeer - Two 6-pacs

 6 cans of Coca Cola  1 gallon of Iced Tea with Splenda and Sweet N Low packets Or Diet Brisk Tea

 6 Sugar Free Red Bull

 Crystal Lite to go – 2 boxes – individual packets –Mio is an acceptable substitution (No Tea Flavors please)

 12 bottles of Corona Beer.

 12 bottles of Miller Lite

 1 -750ml bottle of Grey Goose Vodka – HANDED TO LESLIE or JENNI PERSONALLY

 One bottle of Yellowtail Shiraz red wine or Merlot red wine (or equivalent)

 1 – 32oz. V-8 vegetable juice bottles

 1 – 32oz. Ocean Spray cranberry juice

 24 Bottles of bottled spring water 12 oz. bottles at room temperature

 1 Box of assorted Granola bars

 1 -32 oz orange juice

 ½ Gallon Hood brand Fat Free Carb Countdown or Light Silk Soy Milk

 Decaf Coffee & Regular Tea service and setup, with sugar and Splenda sweetener

 Fresh Ice

 24 Plates, Napkins, Forks, Spoons, salt & pepper, 1 box of quart Zip-Lock bags, and 6 Styrofoam To-Go type of plate containers for food

ALL DRINKS ON ICE AT LEAST 2 HOURS BEFORE SHOWTIME

QUESTIONS?… Call Jenni West 201-496-3452

16. BACKSTAGE PERSONNEL

A. No one except working personnel, performers, and authorized guests permitted backstage or in the ARTIST’S dressing rooms before, during, or after show.

B. During the ARTIST’S performances, only persons actually employed by the ARTIST and authorized guests are to be allowed on stage.

C. The ARTIST’S Road Manager will supply passes for guests of the ARTIST. All passes for stagehands, caterers, security, and other PURCHASER furnished personnel will be supplied by the PURCHASER.

17. TRANSPORTATION/EQUIPMENT LIST FOR FLY – IN DATES ONLY:

TRANSPORTATION FLY-IN DATES ONLY: Purchaser shall provide at no expense to the ARTIST transportation beginning with a pick up at the airport to hotel, to and from concert, and return to the airport. Please coordinate through Jenni West at 201-496-3452 or, if Jenni is unreachable, through the management office.

PLEASE NOTE: Ground transport must be wheelchair accessible

****THIS PAGE REQUIRES PURCHASER’S SINGNATURE****

18. SUPPORT PERSONNEL Any inquiries should be directed to:

Artist Management Bob Ringe President Survival Management, Inc. 30765 Pacific Coast Highway Suite 325 Malibu, CA 90265 310/317-9223 Ph 310/317-9225 F

ACCEPTED TO AND AGREED BY PURCHASER

PURCHASER: ______

TITLE: ______

DATED: ______

***THIS PAGE REQUIRES PURCHASER’S SIGNATURE***