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<br />Date: <br /> <br />WITNESSES: <br /> <br />Printed Name <br /> <br />Street Address <br /> <br />City, State Zip Code <br /> <br />Printed Name <br /> <br />Street Address <br /> <br />City, State Zip Code <br /> <br />, <br />... <br /> <br />GOLD CLUB, INC., <br /> <br />Signature <br /> <br />Signature <br /> <br />Page 8 of9 <br /> <br />..~.@/9 <br />V~l . <br />