Exhibit 10.1
 
NEW GENERATION BIOFUELS HOLDINGS, INC.
SUBSCRIPTION AGREEMENT

New Generation Biofuels Holdings, Inc.
1000 Primera Boulevard, Suite 3130
Lake Mary, Florida 32746

Ladies and Gentlemen:

The undersigned (the “Investor”) hereby confirms its agreement with New
Generation Biofuels Holdings, Inc., a Florida corporation (the “Company”), as
follows:

1.           This Subscription Agreement, including the Terms and Conditions for
Purchase of Units attached hereto as Annex I (collectively, this “Agreement ”)
is made as of the date set forth below between the Company and the Investor.

2.           The Company has authorized the sale and issuance to certain
investors of up to an aggregate of [    ] units (the “Units”), subject to
adjustment by the Company’s Board of Directors or a committee thereof, with each
Unit consisting of: (i) one share (the “Share,” collectively, the “Shares ”) of
its common stock, par value $0.001 per share (the “Common Stock”), and (ii) one
warrant (the “Warrant ,” collectively, the “Warrants”) to purchase 0.2 shares of
Common Stock (and the fractional amount being the “Warrant Ratio”), in
substantially the form attached hereto as Exhibit B, for a purchase price of
$1.05 per Unit (the “Purchase Price ”).  Units will not be issued or
certificated and will not trade on any exchange or be listed for quotation on
any market.  The Shares and Warrants are immediately separable and will be
issued separately.  The shares of Common Stock issuable upon exercise of the
Warrants are referred to herein as the “Warrant Shares” and, together with the
Units, the Shares and the Warrants, are referred to herein as the “Securities”).

3.           The offering and sale of the Units (the “Offering”) are being made
pursuant to: (a) an effective Registration Statement on Form S-3, No. 333-156449
(the “Registration Statement”) filed by the Company with the Securities and
Exchange Commission (the “Commission”), including the Prospectus contained
therein (the “Base Prospectus”), (b) if applicable, certain “free writing
prospectuses” (as that term is defined in Rule 405 under the Securities Act of
1933, as amended (the “Act”)), that have been or will be filed, if required,
with the Commission and delivered to the Investor on or prior to the date hereof
(the “Issuer Free Writing Prospectus”), containing certain supplemental
information regarding the Units, the terms of the Offering and the Company and
(c) a Prospectus Supplement (the “Prospectus Supplement” and, together with the
Base Prospectus, the “Prospectus”) containing certain supplemental information
regarding the Units and terms of the Offering that will be filed with the
Commission and delivered to the Investor (or made available to the Investor by
the filing by the Company of an electronic version thereof 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 Units
set forth below for the aggregate purchase price set forth below.  The Units
shall be purchased pursuant to the Terms and Conditions for Purchase of Units
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 Capstone Investments, the placement agent for the Offering (the
“Placement Agent”) and that there is no minimum offering amount.

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5.           The manner of settlement of the Shares included in the Units
purchased by the Investor shall be determined by such Investor as follows (check
one):

o
A.
Delivery by crediting the account of the Investor’s prime broker (as specified
by such Investor on Exhibit A annexed hereto) with the Depository Trust Company
(“DTC”) through its Deposit/Withdrawal At Custodian (“DWAC”) system, whereby
Investor’s prime broker shall initiate a DWAC transaction on the Closing Date
(as defined on Annex I hereto) using its DTC participant identification number,
and released by Olde Monmouth Stock Transfer Co. Inc., the Company’s transfer
agent (the “Transfer Agent”), at the Company’s direction.  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 SHARES ARE MAINTAINED TO SET UP A DWAC INSTRUCTING THE TRANSFER AGENT TO
CREDIT SUCH ACCOUNT OR ACCOUNTS WITH THE SHARES, AND

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

[Account information to be provided under separate cover]

-- OR --

o
B.
Delivery versus payment (“DVP”) through DTC (i.e., on the Closing  Date, the
Company shall deliver the Shares registered in the Investor’s name and address
as set forth below and released by the Transfer Agent to the Investor through
DTC at the Closing directly to the account(s) at the Placement Agent
identified by the Investor; upon receipt of such Shares, the Placement Agent
shall promptly electronically deliver such Shares to the Investor,
and simultaneously therewith payment shall be made by the Placement Agent by
wire transfer to the Company).  NO LATER THAN ONE (1) BUSINESS DAY AFTER THE
EXECUTION OF THIS AGREEMENT BY THE INVESTOR AND THE COMPANY, THE INVESTOR SHALL:

 
(I)
NOTIFY THE PLACEMENT AGENT OF THE ACCOUNT OR ACCOUNTS AT THE PLACEMENT AGENT TO
BE CREDITED WITH THE SHARES BEING PURCHASED BY SUCH INVESTOR, AND

 

 
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(II)
CONFIRM THAT THE ACCOUNT OR ACCOUNTS AT THE PLACEMENT AGENT TO BE CREDITED WITH
THE SHARES BEING PURCHASED BY THE INVESTOR HAVE A MINIMUM BALANCE EQUAL TO THE
AGGREGATE PURCHASE PRICE FOR THE UNITS 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 PURCHASE PRICE FOR THE UNITS OR
DOES NOT MAKE PROPER ARRANGEMENTS FOR SETTLEMENT IN A TIMELY MANNER, THE SHARES
AND WARRANTS 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 executed Warrant shall be delivered in accordance with the
terms thereof.

7.           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 member of the Financial Industry Regulatory Authority, Inc. or
an Associated Person (as such term is defined under the NASD Membership and
Registration Rules Section 1011) as of the Closing, and (c) neither the Investor
nor any group of Investors (as identified in a public filing made with the
Commission) of which the Investor is a part in connection with the Offering of
the Units, acquired, or obtained the right to acquire, 20% or more of the Common
Stock (or securities convertible into or exercisable for Common Stock) or the
voting power of the Company on a post-transaction basis.

Exceptions:

(Please provide a listing of exceptions to the foregoing representations.  If no
exceptions, write “none.”  If left blank, response will be deemed to be “none.”)

8.           The Investor represents that it has received (or otherwise had made
available to it by the filing by the Company of an electronic version thereof
with the Commission) the Base Prospectus which is a part of the Company’s
Registration Statement, the documents incorporated by reference therein and any
free writing prospectus (collectively, the “Disclosure Package”), prior to or in
connection with the receipt of this Agreement.  The Investor acknowledges that,
prior to the delivery of this Agreement to the Company, the Investor will
receive certain additional information regarding the Offering, including pricing
information (the “Offering Information”).  Such information may be provided to
the Investor by any means permitted under the Act, including the Prospectus
Supplement, a free writing prospectus and oral communications.

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9.           No offer by the Investor to buy Units will be accepted and no part
of the Purchase Price will be delivered to the Company until the Investor has
received the Offering Information and the Company has accepted such offer by
countersigning a copy of this Agreement, and any such offer may be withdrawn or
revoked, without obligation or commitment of any kind, at any time prior to the
Company (or Placement Agent 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 the Investor has been delivered the Offering Information and 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 Units, in whole or
in part.

10.           The Company acknowledges that the only material, non-public
information relating to the Company it has provided to the Investor in
connection with the Offering prior to the date hereof is the existence of the
Offering.

[Signature Page Follows]

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Number of Units: __________
Purchase Price Per Unit: $1.05
Aggregate Purchase Price: $[          ]

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: _____________________________, 2009

INVESTOR:

[                                   ]

By: _____________________
      Name:
      Title:

Address:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Agreed and Accepted
this _____ day of ______________, 2009:

NEW GENERATION BIOFUELS HOLDINGS, INC.

By: _______________________________________
      Name:
      Title:
 
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ANNEX I

TERMS AND CONDITIONS FOR PURCHASE OF UNITS

Capitalized terms used but not defined on this Annex I shall have the meanings
ascribed to such terms in the Subscription Agreement to which this Annex is
attached.

1.           Authorization and Sale of the Units.  Subject to the terms and
conditions of this Agreement, the Company has authorized the sale of the Units.

2.           Agreement to Sell and Purchase the Units; Placement Agent.

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 Units set forth on the last page
of the Agreement to which these Terms and Conditions for Purchase of Units 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 Units 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 Capstone
Investments (the “Placement Agent”) a cash fee and warrants to purchase shares
of Common Stock in respect of the sale of Units to the Investor.

2.4           The Company has entered into a Placement Agent Agreement, dated
July 22, 2009 (the “Placement Agreement”), with the Placement Agent that
contains certain representations, warranties, covenants and agreements of the
Company, each of which may be relied upon by the Investor as if fully set forth
herein.  It is specifically agreed that Investor shall be a third party
beneficiary of all such representations, warranties, covenants and agreements of
the Company.

3.           Closing and Delivery of the Shares, Warrants and Funds.

3.1           Closing.  The completion of the purchase and sale of the Units
(the “Closing”) shall occur at a place and time (the “Closing Date”) to be
specified by the Company and the Placement Agent, and of which the Investors
will be notified in advance by the Placement Agent, 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 Shares 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, (b) the Company shall cause to be delivered to the Investor a
Warrant to purchase a number of whole Warrant Shares determined by multiplying
the number of Shares set forth on the signature page by the Warrant Ratio and
rounding down to the nearest whole number and (c) the aggregate purchase price
for the Units being purchased by the Investor will be delivered by or on behalf
of the Investor to the Company.
 

 
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3.2           Conditions to the Obligations of the Parties.

(a)           Conditions to the Company’s Obligations.  The Company’s obligation
to issue and sell the Units to the Investor shall be subject to: (i) the receipt
by the Company of the purchase price for the Units being purchased hereunder as
set forth on the Signature Page and (ii) the accuracy of the representations and
warranties made by the Investor and the fulfillment of those undertakings of the
Investor to be fulfilled prior to the Closing Date.

(b)           Conditions to the Investor’s Obligations.  The Investor’s
obligation to purchase the Units 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, including
without limitation, those contained in the Placement Agreement, and to the
condition that the Placement Agent 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 Units that they have agreed to purchase from
the Company.  The Investor understands and agrees that, in the event that the
Placement Agent in its sole discretion determines that the conditions to closing
in the Placement Agreement have not been satisfied or if the Placement Agreement
may be terminated for any other reason permitted by the Placement Agreement,
then the Placement Agent may, but shall not be obligated to, terminate the
Placement Agreement, which shall have the effect of terminating this
Subscription Agreement pursuant to Section 14 below.

3.3           Delivery of Funds.
 
(a)             DWAC Delivery.  If the Investor elects to settle the Shares
purchased by such Investor through DTC’s Deposit/Withdrawal at Custodian
(“DWAC”) delivery system, 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 the amount of funds equal to the aggregate purchase price for the
Units being purchased by the Investor to the following account designated by the
Company and the Placement Agent pursuant to the terms of that certain Escrow
Agreement, dated as of the date hereof, by and among the Company, the Placement
Agent and Continental Stock Transfer & Trust Company (the “Escrow Agent”):
 
[Account information to be provided under separate cover]
 
Such funds shall be held in escrow until the Closing and delivered by the Escrow
Agent on behalf of the Investors to the Company upon the satisfaction, in the
sole judgment of the Placement Agent, of the conditions set forth in
Section 3.2(b) hereof.
 
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The Investor acknowledges and agrees that no minimum amount is required to be
raised in order for the Company and the Placement Agent to close the Offering.

(b)           Delivery Versus Payment through The Depository Trust Company.  If
the Investor elects to settle the Shares 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 the Placement Agent to be credited with
the Units being purchased by the Investor have a minimum balance equal to the
aggregate purchase price for the Units being purchased by the Investor.

3.4           Delivery of Shares.

(a)           DWAC Delivery.  If the Investor elects to settle the Shares
purchased by such Investor through DTC’s DWAC delivery system, 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 Shares being purchased by such Investor are
maintained, which broker/dealer shall be a DTC participant, to set up a DWAC
instructing Olde Monmouth Stock Transfer Co. Inc., the Company’s transfer agent
(the “Transfer Agent”), to credit such account or accounts with the Shares.
 Such DWAC instruction shall indicate the settlement date for the deposit of the
Shares, which date shall be provided to the Investor by the Placement
Agent.  Simultaneously with the delivery to the Company by the Escrow Agent of
the funds held in escrow pursuant to Section 3.3 above, the Company shall direct
the Transfer Agent to credit the Investor’s account or accounts with the Shares
pursuant to the information contained in the DWAC.

(b)           Delivery Versus Payment through The Depository Trust Company.  If
the Investor elects to settle the Shares 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
notify the Placement Agent of the account or accounts at the Placement Agent to
be credited with the Shares being purchased by such Investor.  On the Closing
Date, the Company shall deliver the Shares to the Investor through DTC directly
to the account(s) at the Placement Agent identified by Investor and
simultaneously therewith payment shall be made by the Placement Agent by wire
transfer to the Company.

4.           Representations, Warranties and Covenants of the Investor.

The Investor acknowledges, represents and warrants to, and agrees with, the
Company and the Placement Agent 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 Units, 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 Units set
forth on the Signature Page, has received and is relying only upon the
Disclosure Package and the documents incorporated by reference therein and the
Offering Information.

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4.2           (a) No action has been or will be taken in any jurisdiction
outside the United States by the Company or the Placement Agent that would
permit an offering of the Units, 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 Securities or has in its possession or distributes any
offering material, in all cases at its own expense and (c) the Placement Agent
is not authorized to make and has not made any representation, disclosure or use
of any information in connection with the issue, placement, purchase and sale of
the Units, except as set forth or incorporated by reference in the Base
Prospectus or the Prospectus Supplement or any free writing 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 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
Prospectus, the Disclosure Package, the Offering Information or any other
materials presented to the Investor in connection with the purchase and sale of
the Units constitutes legal, tax or investment advice. The Investor has
consulted such legal, tax and investment advisors and made such investigation as
it, in its sole discretion, has deemed necessary or appropriate in connection
with its purchase of Units.  The Investor also understands that there is no
established public trading market for the Warrants being offered in the
Offering, and that the Company does not expect such a market to develop.  In
addition, the Company does not intend to apply for listing the Warrants on any
securities exchange.  Without an active market, the liquidity of the Warrants
will be limited.

4.5           Since the date on which the Placement Agent first contacted the
Investor about the Offering, the Investor has not disclosed any information
regarding the Offering to any third parties (other than its legal, accounting
and other advisors who are bound by agreements or duties of confidentiality) and
has not engaged in any purchases or sales involving the securities of the
Company (including, without limitation, any Short Sales involving the Company’s
securities).  The Investor covenants that it will not engage in any purchases or
sales involving the securities of the Company (including Short Sales) prior to
the time that the transactions contemplated by this Agreement are publicly
disclosed.  The Investor agrees that it will not use any of the Securities
acquired pursuant to this Agreement to cover any short position in the 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.

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5.           Survival of Representations, Warranties and Agreements; Third Party
Beneficiary.  Notwithstanding any investigation made by any party to this
Agreement or by the Placement Agent, all covenants, agreements, representations
and warranties made by the Company and the Investor herein will survive the
execution of this Agreement, the delivery to the Investor of the Shares and
Warrants being purchased and the payment therefor.  It is specifically agreed
that the Placement Agent shall be a third party beneficiary 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 (c) 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 electronic confirmation of
receipt and will be delivered and addressed as follows:

(a)           if to the Company, to:

New Generation Biofuels Holdings, Inc.
1000 Primera Boulevard, Suite 3130
Lake Mary, Florida 32746
Attention: Cary J. Claiborne, President and Chief Executive Officer
Fax Number: (443) 638-0277

with copies (which shall not constitute notice) to:

Hogan & Hartson LLP
555 Thirteenth Street, NW
Washington, DC 20004
Attention: Steven M. Kaufman, Esq.
Fax Number: (202) 637-5910

(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.

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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.  Delivery of a signed counterpart of this
Agreement by facsimile or other electronic transmission shall constitute valid
and sufficient delivery thereof.  The Company and the Investor acknowledge and
agree that the Company shall deliver its counterpart to the Investor along with
the Prospectus Supplement (or the filing by the Company of an electronic version
thereof with the Commission).

12.           Confirmation of Sale.  The Investor acknowledges and agrees that
such Investor’s receipt of the Company’s signed counterpart to this Agreement,
together with the Prospectus Supplement (or the filing by the Company of an
electronic version thereof with the Commission), shall constitute written
confirmation of the Company’s sale of the Units to such Investor.

13.           Press Release.  The Company and the Investor agree that the
Company shall, prior to the opening of the financial markets in New York City on
the business day immediately after the date hereof: (a) issue a press release
announcing the Offering and disclosing all material information regarding the
Offering and (b) file a Current Report on Form 8-K with the Securities and
Exchange Commission including a form of this Agreement and a form of Warrant as
exhibits thereto.

14.           Termination.  In the event that the Placement Agreement is
terminated by the Placement Agent pursuant to the terms thereof, this Agreement
shall terminate without any further action on the part of the parties hereto.

[Exhibit A (Investor Questionnaire) Follows]
 
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EXHIBIT A

NEW GENERATION BIOFUELS HOLDINGS, INC.

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 Shares and Warrants 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:

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Fax: ________________________________________________

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 Shares are maintained):

6.           DTC Participant Number: _________________________________________

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

______________________________________________________________

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

______________________________________________________________
 
 
 
 
 
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