Exhibit 10.1
 
SUBSCRIPTION AGREEMENT
 
Spherix Incorporated
6430 Rockledge Drive, Suite 503
 
Bethesda, MD 20817
 
Gentlemen:
 
The undersigned (the “Investor”) hereby confirms its agreement with you as
follows:
 
1. This Subscription Agreement (this “Agreement”) is made as of the date set
forth below between Spherix Incorporated, a Delaware corporation (the “Company”)
and the Investor.
 
2. The Company has authorized the sale and issuance to certain investors of up
to an aggregate of 10,00,000 shares (the “Securities”) of its Series J Preferred
Stock, par value $0.0001 per share, for a purchase price of $2.00 per Security
(the “Purchase Price”).
 
3. The offering and sale of the Securities (the “Offering”) is being made
pursuant to (1) an effective Registration Statement on Form S-3 (including the
Prospectus contained therein (including any documents incorporated by reference
therein, the “Base Prospectus”) and any documents incorporated by reference
therein, the “Registration Statement”) filed by the Company with the Securities
and Exchange Commission (the “Commission”), (2) if applicable, certain “free
writing prospectuses” (as that term is defined in Rule 405 under the Securities
Act of 1933, as amended), that have or will be filed with the Commission and
delivered to the Investor on or prior to the date hereof and (3) a Final
Prospectus Supplement (the “Final Prospectus Supplement,” and together the Base
Prospectus, the “Final Prospectus”) containing the final terms of the Offering
that has been delivered to the Investor and that will be filed with the
Commission.
 
4. The Company and the Investor agree that the Investor will purchase from the
Company and the Company will issue and sell to the Investor the Securities set
forth below for the aggregate purchase price set forth below. The Securities
shall be purchased pursuant to the Terms and Conditions for Purchase of
Securities attached hereto as Annex I and incorporated herein by this reference
as if fully set forth herein. The Investor acknowledges that the Offering is not
being underwritten by the placement agents (the “Placement Agents”) named in the
Final Prospectus and that there is no minimum offering amount.
 
5. The manner of settlement of the Securities purchased by the Investor shall be
determined by such Investor as set forth below (check one). Notwithstanding the
foregoing, in the event none of the below delivery options are available, all
payments by the the Investor will be deposited by the Investor as soon as
practicable with the Escrow Agent (as defined in Annex I) and the Company shall
cause to be delivered, on the Closing Date, certificates representing the
Securities registered in the Investor’s name and address as set forth below to
such Investor.

 
 

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[       ]      A. Delivery by electronic book-entry at The Depository Trust
Company (“DTC”), registered in the Investor’s name and address as set forth
below, and released by Equity Stock Transfer LLC, the Company’s transfer agent
(the “Transfer Agent”), to the Investor at the Closing. NO LATER THAN ONE (1)
BUSINESS DAY AFTER THE EXECUTION OF THIS AGREEMENT BY THE INVESTOR AND THE
COMPANY, THE INVESTOR SHALL:
 
(I)  
DIRECT THE BROKER-DEALER AT WHICH THE ACCOUNT OR ACCOUNTS TO BE CREDITED WITH
THE SECURITIES ARE MAINTAINED TO SET UP A DEPOSIT/WITHDRAWAL AT CUSTODIAN
(“DWAC”) INSTRUCTING THE TRANSFER AGENT TO CREDIT SUCH ACCOUNT OR ACCOUNTS WITH
THE SECURITIES, AND

 
(II)  
REMIT BY WIRE TRANSFER THE AMOUNT OF IMMEDIATELY AVAILABLE FUNDS EQUAL TO THE
AGGREGATE PURCHASE PRICE FOR THE SECURITIES BEING PURCHASED BY THE INVESTOR TO
THE FOLLOWING ACCOUNT:

[_______]
 
— OR —
 
[       ]      B. Delivery versus payment (“DVP”) through DTC (i.e., the Company
shall deliver Securities registered in the Investor’s name and address as set
forth below and released by the Transfer Agent to the Investor at the Closing
directly to the account(s) at Laidlaw & Company (UK) Ltd. (“Laidlaw”) identified
by the Investor and simultaneously therewith payment shall be made in
immediately available funds from such account(s) to the Company through DTC). NO
LATER THAN ONE (1) BUSINESS DAY AFTER THE EXECUTION OF THIS AGREEMENT BY THE
INVESTOR AND THE COMPANY, THE INVESTOR SHALL:
 
(I)  
NOTIFY LAIDLAW OF THE ACCOUNT OR ACCOUNTS AT LAIDLAW TO BE CREDITED WITH THE
SECURITIES BEING PURCHASED BY SUCH INVESTOR, AND

 
(II)  
CONFIRM THAT THE ACCOUNT OR ACCOUNTS AT LAIDLAW TO BE CREDITED WITH THE
SECURITIES BEING PURCHASED BY THE INVESTOR HAVE A MINIMUM BALANCE EQUAL TO THE
AGGREGATE PURCHASE PRICE FOR THE SECURITIES BEING PURCHASED BY THE INVESTOR.

 
IT IS THE INVESTOR’S RESPONSIBILITY TO (A) MAKE THE NECESSARY WIRE  TRANSFER OR
CONFIRM THE PROPER ACCOUNT BALANCE IN A TIMELY  MANNER AND (B) ARRANGE FOR
SETTLEMENT BY WAY OF DWAC OR DVP IN  A TIMELY MANNER. IF THE INVESTOR DOES NOT
DELIVER THE AGGREGATE

 
 

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PURCHASE PRICE FOR THE SECURITIES IN IMMEDIATELY AVAILABLE FUNDS  OR DOES NOT
MAKE PROPER ARRANGEMENTS FOR SETTLEMENT IN A  TIMELY MANNER, THE SECURITIES MAY
NOT BE DELIVERED AT CLOSING TO  THE INVESTOR OR THE INVESTOR MAY BE EXCLUDED
FROM THE CLOSING  ALTOGETHER, AT THE COMPANY’S DISCRETION.
 
6.           The Investor represents that, except as set forth below, (a) it has
had no position,
 
office or other material relationship within the past three years with the
Company or persons known to it to be affiliates of the Company, (b) it is not a
FINRA member or an Associated Person (as such term is defined under the NASD
Membership and Registration Rules Section 1011) as of the Closing, and (c) it,
after giving effect to the transactions contemplated hereby and subject to any
other voluntary limitations requested by the Investors, will not, either
individually or with a group (as defined in Section 13(d)(3) of the Securities
Exchange Act of 1934, as amended (the “Exchange Act”)), be the beneficial owner
of 20% or more of the Company’s outstanding common stock. For purposes of this
Section 6, beneficial ownership shall be determined pursuant to a Rule 13d-3
under the Exchange Act. Exceptions:
 
________________________________________________________________
(If no exceptions, write “none.” If left blank, response will be deemed to be
“none.”)
 
7. The Investor represents that it has received (i) the final Base Prospectus,
which is a part of the Company’s Registration Statement, (ii) the documents
incorporated by reference therein (or otherwise made available to it by the
filing by the Company of an electronic version thereof with the Commission) and
(iii) any free writing prospectus (collectively, the “Disclosure Package”) prior
to the execution by the Investor of this Agreement. The Investor understands
that prior to delivery of this Agreement to the Company the Investor will
receive the Final Prospectus.
 
8. No offer by the Investor to buy Securities will be accepted and no part of
the Purchase Price will be delivered to the Company until the Investor has
received the Final Prospectus and the Company has accepted such offer by
countersigning a copy of this Agreement, and any such offer may be withdrawn or
revoked by the Investor, without obligation or commitment of any kind, at any
time prior to the Company (or a Placement Agents on behalf of the Company)
sending (orally, in writing, or by electronic mail) notice of its acceptance of
such offer. An indication of interest will involve no obligation or commitment
of any kind until this Agreement is accepted and countersigned by or on behalf
of the Company. The Investor understands and agrees that the Company, in its
sole discretion, reserves the right to accept or reject this subscription for
Securities, in whole or in part.

 
 

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Number of Securities:_______________________________________
 
Purchase Price Per Securities: _________________________________
 
Aggregate Purchase Price: $ __________________________________
 
Election of 4.99% Beneficial Ownership Limitation (as defined in the Certificate
of Designation of Preferences, Rights and Limitations of Series J Convertible
Preferred Stock)__________
 
Please confirm that the foregoing correctly sets forth the agreement between us
by signing in the space provided below for that purpose.
 
Dated as of: May 28, 2014
 
____________________
INVESTOR
By:
Print Name:
Title:
Address:
 
 
Agreed and Accepted
this 28th day of May, 2014:
 
 
SPHERIX INCORPORATED
 
By:
Title:

 
 

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ANNEX I
 
TERMS AND CONDITIONS FOR PURCHASE OF SECURITIES
 
1. Authorization and Sale of the Securities. Subject to the terms and conditions
of this Agreement, the Company has authorized the sale of the Securities.
 
2. Agreement to Sell and Purchase the Securities; Placement Agents.
 
2.1           At the Closing (as defined in Section 3.1), the Company will sell
to the Investor,
and the Investor will purchase from the Company, upon the terms and conditions
set forth herein, the number of Securities set forth on the last page of the
Agreement to which these Terms and Conditions for Purchase of Securities are
attached as Annex I (the “Signature Page”) for the aggregate purchase price
therefor set forth on the Signature Page.
 
2.2           The Company proposes to enter into substantially this same form of
Subscription
Agreement with certain other investors (the “Other Investors”) and expects to
complete sales of Securities to them. The Investor and the Other Investors are
hereinafter sometimes collectively referred to as the “Investors,” and this
Agreement and the Subscription Agreements executed by the Other Investors are
hereinafter sometimes collectively referred to as the “Agreements.”
 
2.3           Investor acknowledges that the Company has agreed to pay Laidlaw &
Company
(UK) Ltd. (the “Placement Agents”) a fee (the “Placement Fee”) in respect of the
sale of Securities to the Investor.
 
2.4           The Company has entered into a Placement Agency Agreement, dated
May 28,
2014 (the “Placement Agreement”), with the Placement Agents. Under Section 2 of
the Placement Agreement, the Company has made representations and warranties to
the Placement Agents and the Investors, which the Investors shall be entitled to
rely upon as third party beneficiaries thereof.
 
3. Closings and Delivery of the Securities and Funds.
 
3.1           Closing. The completion of the purchase and sale of the Securities
(the
“Closing”) shall occur at a place and time (the “Closing Date”) to be specified
by the Company and the Representative (as defined in the Placement Agreement),
and of which the Investors will be notified in advance by the Placement
Agreement, in accordance with Rule 15c6-1 promulgated under the Securities
Exchange Act of 1934, as amended (the “Exchange Act”). At the Closing, (a) the
Company shall cause the Transfer Agent to deliver to the Investor the number of
Securities set forth on the Signature Page registered in the name of the
Investor or, if so indicated on the Investor Questionnaire attached hereto as
Exhibit A, in the name of a nominee designated by the Investor and (b) the
aggregate purchase price for the Securities being purchased by the Investor will
be delivered by or on behalf of the Investor to the Company in immediately
available funds.
 
3.2           Conditions to the Company’s Obligations. The Company’s obligation
to issue
and sell the Securities to the Investor shall be subject to: (i) the receipt by
the Company of the purchase price for the Securities being purchased hereunder
in immediately available funds as set

 
 

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forth on the Signature Page and (ii) the accuracy of the representations and
warranties made by the Investor pursuant to this Agreement, including the Terms
and Conditions for Purchase of Securities, and the fulfillment of those
undertakings of the Investor to be fulfilled prior to the Closing Date pursuant
to this Agreement, including the Terms and Conditions for Purchase of
Securities.
 
3.3           Conditions to the Investor’s Obligations. The Investor’s
obligation to purchase
 
the Securities will be subject to the accuracy of the representations and
warranties made by the Company and the fulfillment of those undertakings of the
Company to be fulfilled prior to the Closing Date pursuant to this Agreement and
Section 7 of the Placement Agreement, and to the condition that the Placement
Agents shall not have: (i) terminated the Placement Agreement pursuant to the
terms thereof or (ii) determined that the conditions to the closing in the
Placement Agreement have not been satisfied. The Investor’s obligations are
expressly not conditioned on the purchase by any or all of the Other Investors
of the Securities that they have agreed to purchase from the Company.
 
3.4           Delivery of Funds.
 
(a)           Delivery by Electronic Book-Entry at The Depository Trust Company.
If
 
the Investor elects to settle the Securities purchased by such Investor through
delivery by electronic book-entry at DTC, no later than one (1) business day
after the execution of this  Agreement by the Investor and the Company, the
Investor shall remit by wire transfer of immediately available funds the amount
of funds equal to the aggregate purchase price for the Securities being
purchased by the Investor to the following account designated by the Company and
the Placement Agents pursuant to the terms of that certain Escrow Agreement (the
“Escrow Agreement”) dated as of May 28, 2014, by and among the Company, the
Placement Agents and Signature Bank (the “Escrow Agent”):
 
Signature Bank
261 Madison Avenue
New York, NY 10016
Account Name: Signature Bank as Escrow Agent for Spherix Incorporated
ABA Number: 026013576
SWIFT Code: SIGNUS33
A/C Number: 1502261750
FBO: Purchase Name, Social Security Number, Address
 
Such funds shall be held in escrow until the Closing and delivered by the Escrow
Agent on behalf of each Investor to the Company upon the satisfaction, in the
sole judgment of the Representative, of the conditions set forth in Section 3.3
hereof. The Representative shall have no rights in or to any of the escrowed
funds, unless the Representative and the Escrow Agent are notified in writing by
the Company in connection with the Closing that a portion of the escrowed funds
shall be applied to the Placement Fee. The Company and the Investor agree to
indemnify and hold the Escrow Agent harmless from and against any and all
losses, costs, damages,

 
 

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expenses and claims (including, without limitation, court costs and reasonable
attorneys fees) (“Losses”) arising under this Section 3.4 or otherwise with
respect to the funds held in escrow pursuant hereto or arising under the Escrow
Agreement, unless it is finally determined that such Losses resulted directly
from the bad faith, willful misconduct or gross negligence of the Escrow Agent.
Anything in this Agreement to the contrary notwithstanding, in no event shall
the Escrow Agent be liable for any special, indirect or consequential loss or
damage of any kind whatsoever (including but not limited to lost profits), even
if the Escrow Agent has been advised of the likelihood of such loss or damage
and regardless of the form of action.
 
Investor shall also furnish to the Representative a completed W-9 form (or, in
the case of an Investor who is not a United States citizen or resident, a W-8
form).
 
(b)            Delivery Versus Payment through The Depository Trust Company. If
the Investor elects to settle the Securities purchased by such Investor by
delivery versus payment through DTC, no later than one (1) business day after
the execution of this Agreement by  the Investor and the Company, the Investor
shall confirm that the account or accounts at Laidlaw Capital LLC (“Laidlaw”) to
be credited with the Securities being purchased by the Investor have a minimum
balance in immediately available funds equal to the aggregate purchase price for
the Securities being purchased by the Investor.
 
(c)            Physical Certificate Delivery. Notwithstanding anything herein to
the contrary, in the event that the delivery options described in Sections
3.4(a) or 3.4(b) are unavailable, and the Company settles the Securities
purchased by such Investor by delivery of physical certificates representing the
Securities purchased, the Investor shall remit by wire transfer of immediately
available funds the amount of funds equal to the aggregate purchase price for
the Securities being purchased by the Investor to the Escrow Account in the same
manner as set forth in Section 3.4(a) herein.
 
3.5           Delivery of Securities.
 
(a)            Delivery by Electronic Book-Entry at The Depository Trust
Company. If the Investor elects to settle the Securities purchased by such
Investor through delivery by electronic book-entry at DTC, no later than one (1)
business day after the execution of this  Agreement by the Investor and the
Company, the Investor shall direct the broker-dealer at which the account or
accounts to be credited with the Securities being purchased by such Investor are
maintained, which broker/dealer shall be a DTC participant, to set up a
Deposit/Withdrawal at Custodian (“DWAC”) instructing Equity Stock Transfer LLC,
the Company’s transfer agent, to credit such account or accounts with the
Securities by means of an electronic book-entry delivery. Such DWAC shall
indicate the settlement date for the deposit of the Securities, which date shall
be provided to the Investor by the Representative. Simultaneously with the
delivery to the Company by the Escrow Agent of the funds held in escrow pursuant
to Section 3.4 above, the Company shall direct its transfer agent to credit the
Investor’s account or accounts with the Securities pursuant to the information
contained in the DWAC.
 
(b)            Delivery Versus Payment through The Depository Trust Company. If
the Investor elects to settle the Securities purchased by such Investor by
delivery versus payment

 
 

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through DTC, no later than one (1) business day after the execution of this
Agreement by  the Investor and the Company, the Investor shall notify Laidlaw of
the account or accounts at Laidlaw to be credited with the Securities being
purchased by such Investor. On the Closing Date, the Company shall deliver the
Securities to the Investor directly to the account(s) at Laidlaw identified by
Investor and simultaneously therewith payment shall be made in immediately
available funds from such account(s) to the Company through DTC.
 
(c)           Physical Certificate Delivery. If the delivery options set forth
in Sections
3.5(a) and 3.5(b) are unavailable and the Company settles the Securities
purchased by such Investor by delivery of physical certificates representing the
Securities purchased, the Investor shall remit by wire transfer of immediately
available funds the amount of funds equal to the aggregate purchase price for
the Securities being purchased by the Investor to the Escrow Account in the same
manner as set forth in Section 3.4(a) herein and the Company shall cause to be
delivered, on the Closing Date, certificates representing the Securities
registered in the Investor’s name and address as set forth on the Signature Page
to such Investor.
 
4.           Representations, Warranties and Covenants of the Investor.
 
The Investor represents and warrants to, and agrees with, the Company and the
Placement Agents that:
 
4.1           The Investor (a) is knowledgeable, sophisticated and experienced
in making, and
is qualified to make decisions with respect to, investments in shares presenting
an investment decision like that involved in the purchase of the Securities,
including investments in securities issued by the Company and investments in
comparable companies, (b) has answered all questions on the Signature Page and
the Investor Questionnaire and the answers thereto are true and correct as of
the date hereof and will be true and correct as of the Closing Date and (c) in
connection with its decision to purchase the number of Securities set forth on
the Signature Page, has received and is relying only upon the Disclosure Package
and the Final Prospectus and the documents incorporated by reference therein.
 
4.2           (a) No action has been or will be taken in any jurisdiction
outside the United
States by the Company or the Placement Agents that would permit an offering of
the Securities, or possession or distribution of offering materials in
connection with the issue of the Securities in any jurisdiction outside the
United States where action for that purpose is required, (b) if the Investor is
outside the United States, it will comply with all applicable laws and
regulations in each foreign jurisdiction in which it purchases, offers, sells or
delivers the Securities or has in its possession or distributes any offering
material, in all cases at its own expense and (c) the Placement Agents have not
been authorized to make and have not made any representation, disclosure or use
of any information in connection with the issue, placement, purchase and sale of
the Securities, except as set forth or incorporated by reference in the Base
Prospectus or the Final Prospectus.
 
4.3           (a) The Investor has full right, power, authority and capacity to
enter into this
 
Agreement and to consummate the transactions contemplated hereby and has taken
all necessary action to authorize the execution, delivery and performance of
this Agreement, and (b) this Agreement constitutes a valid and binding
obligation of the Investor enforceable against the

 
 

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Investor in accordance with its terms, except as enforceability may be limited
by applicable bankruptcy, insolvency, reorganization, moratorium or similar laws
affecting creditors’ and contracting parties’ rights generally and except as
enforceability may be subject to general principles of equity (regardless of
whether such enforceability is considered in a proceeding in equity or at law)
and except as to the enforceability of any rights to indemnification or
contribution that may be violative of the public policy underlying any law, rule
or regulation (including any federal or state securities law, rule or
regulation).
 
4.4           The Investor understands that nothing in this Agreement, the
General Disclosure
Package, the Final Prospectus or any other materials presented to the Investor
in connection with the purchase and sale of the Securities constitutes legal,
tax or investment advice. The Investor has consulted such legal, tax and
investment advisors as it, in its sole discretion, has deemed necessary or
appropriate in connection with its purchase of Securities.
 
4.5           Since the time on which the Placement Agents first contacted such
Investor about
the Offering, such Investor has not engaged in any transactions in the
securities of the Company (including, without limitation, any Short Sales
involving the Company’s securities). Each Investor covenants that it will not
engage in any transactions in the securities of the Company (including Short
Sales) prior to the time that the transactions contemplated by this Agreement
are publicly disclosed. Each Investor agrees that it will not use any of the
Securities acquired pursuant to this Agreement to cover any short position in
the Company’s common stock if doing so would be in violation of applicable
securities laws. For purposes hereof, “Short Sales” include, without limitation,
all “short sales” as defined in Rule 200 promulgated under Regulation SHO under
the Exchange Act, whether or not against the box, and all types of direct and
indirect stock pledges, forward sales contracts, options, puts, calls, short
sales, swaps, “put equivalent positions” (as defined in Rule 16a-1(h) under the
Exchange Act) and similar arrangements (including on a total return basis), and
sales and other transactions through non-US broker dealers or foreign regulated
brokers.
 
5. Survival of Representations, Warranties and Agreements; Third Party
Beneficiary. Notwithstanding any investigation made by any party to this
Agreement or by the Placement Agents, all covenants, agreements, representations
and warranties made by the Company and the Investor herein will survive the
execution of the Agreement, the delivery to the Investor of the Securities being
purchased and the payment therefor. The Placement Agents shall be third party
beneficiaries with respect to the representations, warranties and agreements of
the Investor in Section 4 hereof.
 
6. Notices. All notices, requests, consents and other communications hereunder
will be in writing, will be mailed (a) if within the domestic United States by
first-class registered or certified airmail, or nationally recognized overnight
express courier, postage prepaid, or by facsimile or (b) if delivered from
outside the United States, by International Federal Express or facsimile, and
will be deemed given (i) if delivered by first-class registered or certified
mail domestic, three business days after so mailed, (ii) if delivered by
nationally recognized overnight carrier, one business day after so mailed, (iii)
if delivered by International Federal Express, two business days after so mailed
and (iv) if delivered by facsimile, upon electric confirmation of receipt and
will be delivered and addressed as follows:

 
 

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(a) if to the Company, to:
 
Spherix Incorporated
6430 Rockledge Drive, Suite 503
Bethesda, MD 20817
Attention: Anthony Hayes, Chief Executive Officer
Fax No:
 
with a copy (which shall not constitute notice) to:
 
(b) if to the Investor, at its address on the Signature Page hereto, or at such
other address or addresses as may have been furnished to the Company in writing.
 
7. Changes. This Agreement may not be modified or amended except pursuant to an
instrument in writing signed by the Company and the Investor.
 
8. Headings. The headings of the various sections of this Agreement have been
inserted for convenience of reference only and will not be deemed to be part of
this Agreement.
 
9. Severability. In case any provision contained in this Agreement should be
invalid, illegal or unenforceable in any respect, the validity, legality and
enforceability of the remaining provisions contained herein will not in any way
be affected or impaired thereby.
 
10. Governing Law. This Agreement will be governed by, and construed in
accordance with, the internal laws of the State of New York, without giving
effect to the principles of conflicts of law that would require the application
of the laws of any other jurisdiction.
 
11. Counterparts. This Agreement may be executed in two or more counterparts,
each of which will constitute an original, but all of which, when taken
together, will constitute but one instrument, and will become effective when one
or more counterparts have been signed by each party hereto and delivered to the
other parties.
 
12. Confirmation of Sale. The Investor acknowledges and agrees that such
Investor’s receipt of the Company’s counterpart to this Agreement shall
constitute written confirmation of the Company’s sale of Securities to such
Investor and an acceptance of such Investor’s offer to purchase such Securities.
 
13. Press Release. The Company and the Investor agree that the Company shall
issue one or more press releases (a) announcing the Offering and (b) disclosing
any material, non-public information regarding the proposed restructuring of the
Company that was described in the Final Prospectus prior to the opening of the
financial markets in New York City on the business day immediately after the
date hereof.

 
 

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14. Termination. In the event that the Placement Agreement is terminated by the
Placement Agents pursuant to the terms thereof, the Agreement shall terminate
without any further action on the part of the parties hereto.
 
15. Assignability of Agreement. The Agreement and the Investor’s rights,
obligations and interest under the Agreement, including the Terms and Conditions
for Purchase of Securities, are not transferable or assignable by the Investor.

 
 

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EXHIBIT A
 
SPHERIX INCORPORATED
 
INVESTOR QUESTIONNAIRE
 
Pursuant to Section 3 of Annex I to the Agreement, please provide us with the
following information:
 
1.  
The exact name that your Securities are to be registered in. You may use a
nominee name if appropriate:

 
2.  
The relationship between the Investor and the registered holder listed in
response to item 1 above:

 
3.  
The mailing address of the registered holder listed in response to item 1 above:

 
4.  
The Social Security Number or Tax Identification Number of the registered holder
listed in the response to item 1 above:

 
5.  
Name of DTC Participant (broker-dealer at which the account or accounts to be
credited with the Securities are maintained):

 
6.  
DTC Participant Number:

 
7.  
Name of Account at DTC Participant being credited with the Securities:

 
8.  
Account Number at DTC Participant being credited with the Securities: