Exhibit 10.1

SECURITIES PURCHASE AGREEMENT

Diagnostic Imaging International Corporation

848 N. Rainbow Blvd. #2494

Las Vegas, Nevada  89107

The undersigned (the "Investor") hereby confirms its agreement with you as
follows:

1.

This Securities Purchase Agreement is made as of the date set forth below
between Diagnostic Imaging International Corporation, a Nevada corporation (the
"Company"), and the Investor, which is one of multiple investors making an
aggregate investment of up to $300,000. The Company reserves the right to sell
additional securities for a larger aggregate investment, without notice to the
Investor, and the Investor may experience dilution in respect of any sales
beyond the above stated amount.

2.

The Company and the Investor agree that the Investor will purchase from the
Company and the Company will issue and sell to the Investor for an aggregate
purchase price of $ _____________(the “Purchase Price”), a Convertible
Promissory Note in principal amount equal to the Purchase Price (the “Note”),
with an initial conversion price of $0.10 for one share (a “Note Share” or if
more than one Note Share the “Note Shares”) of the Company's common stock, par
value $0.001 per share (the “Common Stock”).  The Note will bear interest at the
rate of 12% per annum, payable monthly, with the principal due on
______________, 20___.  In addition, the Company and the Investor agree that
there is a greater risk inherent in a larger investment by an Investor, and
therefore the Company and the Investor agree to compensate the Investor for the
greater risk, at Closing, the Company will instruct its transfer agent to issue
to the Investor as a supplemental investment for the same amount invested, and
not in connection with the conversion of the Note, a number of shares of its
Common Stock as follows: (i) for the portion of an investment in this offering
including and between $1 and $25,000, the Investor will be issued one share for
each dollar invested in the Note, (ii) for the portion of an investment in this
offering including and between $ 25,001 and $75,000, the Investor will be issued
two shares for each dollar invested in the Note, and (iii) for the portion of an
investment in this offering including and more than $ 75,001, the Investor will
be issued three shares for each dollar invested in the Note, and (the common
stock being issue pursuant to the foregoing being referred to as the “Shares”).
[As an example of the issuance of the Shares, if an Investor invests $35,000,
the Investor will receive a Note for $35,000 in principal amount, and 45,000
Shares, calculated as follows – [25,000 time 1] plus [(35,000- 25,000)  times
2].]  Together the Note and Shares are referred to as the “Securities”.

3.

The Company and the Investor agree that the purchase and sale of the Note and
issuance of the Shares is subject to the Terms and Conditions for Purchase
attached hereto as Annex I and incorporated herein by reference as if fully set
forth herein. Unless otherwise requested by the Investor in Exhibit A, the Note
and Shares issued to the Investor will be issued in the Investor's name and
address as set forth below. The form of Note is attached hereto as Exhibit B.

4.

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 its affiliates, other than as a passive stockholder, if at all,
(b) neither it, nor any group of which it is a member or to which it is related,
beneficially owns (including the right to acquire or vote) any securities of the
Company that is greater than 5% of the current issued and outstanding shares of
common stock as reported in the latest report filed by the Company with the
United States Securities and Exchange Commission, and (c) neither it, nor any
affiliate of the Investor, has any direct or indirect affiliation or association
with any Finance and Regulatory Authority, Inc. ("FINRA") member. Exceptions:

(If no exceptions, write "none." If left blank, response will be deemed to be
"none.")

______________________________________________________________________________

--------------------------------------------------------------------------------

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: _______________, 2012

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By:

 

 

 

 

Name:

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGREED AND ACCEPTED:

DIAGNOSTIC IMAGING INTERNATIONAL CORPORATION

By: ____________________

      Name: Mitchell Geisler

      Title: Chief Executive Officer

--------------------------------------------------------------------------------

[SECURITIES PURCHASE AGREEMENT SIGNATURE PAGE]

--------------------------------------------------------------------------------

Annex I

Terms and Conditions for Purchase of Securities

1.

Agreement to Sell and Purchase Securities.

1.1

Purchase and Sale. At the Closing (as defined in Section 2), the Company will
sell to the Investor, and the Investor will purchase from the Company, upon the
terms and subject to the conditions set forth herein, for a the Purchase Price,
the Note and Shares described in Paragraph 2 of the Securities Purchase
Agreement attached hereto (collectively with this Annex I and the other exhibits
attached hereto, this “Agreement” and together with the Note, the “Transaction
Documents”).

1.2

Investor. The Investor must execute and deliver a Securities Purchase Agreement,
and must complete a Certificate Questionnaire (in the form attached as Exhibit A
hereto) and an Investor Questionnaire (in the form attached as Exhibit C hereto)
in order to purchase the Securities.

2.

Delivery at Closing.  The completion of the purchase and sale of the Securities
(the “Closing”) shall occur on a date mutually agreed upon by the Company and
the Investor (the “Closing Date”). At the Closing, the Company shall deliver to
the Investor a Note representing the aggregate dollar amount of the Note set
forth in Paragraph 2 of the Securities Purchase Agreement, and shall instruct
its transfer agent to issue (the “Instruction Letter”) to the Investor that
number of Shares relevant to the investment, as set forth in Paragraph 2 of the
Securities Purchase Agreement. In exchange for the delivery of the Note and
Shares, the Investor shall pay the Purchase Price to the Company by wire
transfer of immediately available funds pursuant to the Company's written
instructions.

The Company's obligation to issue and sell the Securities to the Investor shall
be subject to the satisfaction of the following conditions, any one or more of
which may be waived by the Company: (a) prior receipt by the Company of a copy
of this Agreement executed by the Investor; and (b) the accuracy of the
representations and warranties made by the Investor in this Agreement.

The Investor's obligation to purchase the Securities shall be subject to the
satisfaction of the following conditions, any one or more of which may be waived
by the Investor: (a) the accuracy of the representations and warranties made by
the Company in this Agreement; (b) the execution and delivery by the Company of
the Note and the Instruction Letter; and (c) the fulfillment of the obligations
of the Company under this Agreement on or prior to the Closing.

3.

Representations and Warranties of the Company.  Except as set forth on Schedule
3 attached hereto and incorporated herein by reference or in the SEC Reports (as
defined below), the Company hereby represents and warrants to the Investor as of
the date hereof and the Closing Date, as follows:

3.1

Organization. The Company is a corporation duly organized and validly existing
under, and by virtue of, the laws of the State of Nevada and is in good standing
under such laws, and is qualified and in good standing under the laws of each
other jurisdiction in which it is required to be so qualified.

3.2

Corporate Power. The Company has all requisite corporate power and authority to
own and operate its properties and assets, and to carry on its business as
presently conducted.  The Company has all requisite legal and corporate power
and authority to execute and deliver the Transaction Documents and to carry out
and perform its obligations under the terms of the Transaction Documents.

1

--------------------------------------------------------------------------------

3.3

Authorization; Validity. The execution, delivery and performance of the
Transaction Documents by the Company has been duly authorized by all requisite
corporate action and the Transaction Documents constitute the valid and binding
obligations of the Company, enforceable against it in accordance with its terms,
except as limited by general equitable principles and applicable bankruptcy,
insolvency, reorganization, moratorium and other laws of general application
affecting enforcement of creditors’ rights generally.  The Shares are, and the
Note Shares when issued shall be, duly authorized, validly issued, fully paid
and non-assessable.

3.4

Non-Contravention.  Neither the execution, delivery nor performance of any of
the Transaction Documents has or will result in a violation or conflict with or
constitute, with or without the passage of time or giving of notice or both,
either a default under any provision of the Company’s articles of incorporation
or by-laws or any agreement, instrument or contract to which it is a party or by
which it is bound and that has been filed as an exhibit to the SEC Reports.

3.5

Capitalization. The authorized capital stock of the Company consists of
100,000,000 shares of Common Stock, of which 23,121,481 shares are outstanding,
and 5,000,000 shares of Preferred Stock, par value $0.001 per share, of which no
shares are outstanding. Other than as set forth in the Company’s filings made
under the Securities Exchange Act of 1934, as amended (the “SEC Reports”), there
are no outstanding rights, warrants or options to acquire, or instruments
convertible into or exchangeable for, any shares of capital stock or other
equity interest in the Company, or any such convertible or exchangeable
securities or any such rights, warrants or options.

3.6

Compliance with Laws. The Company is not in material violation of, and neither
the execution, delivery nor performance of any of the Transaction Documents has
or will result in a material violation of, any federal, state, local or foreign
law, rule, regulation, order, judgment or decree applicable to the Company.

3.7

Governmental Permits, Etc. The Company has all material franchises, licenses,
certificates and other authorizations from any foreign, federal, state or local
government or governmental agency, department or body reasonably necessary for
the operation of the business of the Company as currently conducted.

3.8  Accurate Information.  All disclosure furnished by the Company to the
Investor regarding the Company, its business and the transactions contemplated
hereby, is true and correct in all material respects.  

4.

Representations and Warranties of the Investor.  The Investor hereby represents
and warrants to the Company as of the date hereof and the Closing Date, as
follows:

2

--------------------------------------------------------------------------------

4.1

Investor Knowledge and Status. The Investor represents and warrants to, and
covenants with, the Company that: (i) the Investor is an "accredited investor"
as defined in Regulation D under the Securities Act of 1933, as amended (the
“Securities Act”), is knowledgeable, sophisticated and experienced in making,
and is qualified to make decisions with respect to, investments in restricted
securities of micro-cap companies presenting an investment decision similar to
that involved in the purchase of the Securities and Note Shares, and has
requested, received, reviewed and considered all information it deemed relevant
in making an informed decision to purchase the Securities; (ii) the Investor
understands that the Shares and Note Shares will be “restricted securities” when
issued and will not have been registered under the Securities Act and will be
acquiring the Note, the Note Shares and Shares in the ordinary course of its
business and for its own account for investment only, has no present intention
of distributing any of the Note Shares or Shares and has no arrangement or
understanding with any other persons regarding the distribution of the Note
Shares or Shares; and (iii) the Investor has, in connection with its decision to
purchase the Securities, relied only upon the representations and warranties of
the Company contained herein and the information contained in the SEC Reports.
The Investor understands that the issuance of the Securities, and the future
issuance of the Note Shares, to the Investor have not been registered under the
Securities Act, or registered or qualified under any state securities law, in
reliance on specific exemptions therefrom, which exemptions may depend upon,
among other things, the representations made by the Investor in this Agreement.
No person is authorized by the Company to provide any representation that is
inconsistent with or in addition to those contained herein or in the SEC
Reports, and the Investor acknowledges that it has not received or relied on any
such representations.

4.2

Power. The Investor has all requisite power and authority to execute and deliver
this Agreement and to carry out and perform its obligations under the terms of
this Agreement.

4.3

Authorization; Validity.   The execution, delivery and performance by the
Investor of the transactions contemplated by this Agreement have been duly
authorized by any necessary corporate or similar action on the part of the
Investor. This Agreement has been duly executed by the Investor and constitutes
the valid and binding obligation of the Investor, enforceable against it in
accordance with its terms, except as limited by general equitable principles and
applicable bankruptcy, insolvency, reorganization, moratorium and other laws of
general application affecting enforcement of creditors’ rights generally.

4.8

Additional Acknowledgement. The Investor acknowledges that it has independently
evaluated the merits of the transactions contemplated by this Agreement, that it
has independently determined to enter into the transactions contemplated hereby,
that it is not relying on any advice from or evaluation by any other person,
that it is relying solely upon the representations and warranties of the Company
set forth in this Agreement in making its investment decision, and that it is
not acting in concert with any other person in making its purchase of the
Securities hereunder.

5.

Transfer Restrictions; Legends. Certificates evidencing the Note, the Shares and
the Note Shares (the “Legended Shares”) shall each bear any legend as required
by the "blue sky" laws of any state and a restrictive legend in substantially
the following form, until such time as they are not required:

THESE SECURITIES HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS
AMENDED (THE "SECURITIES ACT"), OR APPLICABLE STATE SECURITIES LAWS. THE
SECURITIES MAY NOT BE OFFERED FOR SALE, SOLD, TRANSFERRED OR ASSIGNED (I) IN THE
ABSENCE OF (A) AN EFFECTIVE REGISTRATION STATEMENT FOR THE SECURITIES UNDER THE
SECURITIES ACT OR (B) AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT
SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN
ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS OR BLUE SKY LAWS AS EVIDENCED
BY A LEGAL OPINION OF COUNSEL REASONABLY SATISFACTORY TO THE COMPANY AND ITS
TRANSFER AGENT OR (II) UNLESS SOLD PURSUANT TO RULE 144 UNDER SAID ACT.

3

--------------------------------------------------------------------------------

6.

Public Statements.  The Company agrees to disclose on a Current Report on Form
8-K the consummation of the sale of the Securities and the material terms
thereof, including pricing, which shall be filed with the Securities and
Exchange Commission within four Business Days after the Closing. The Company
will not issue any public statement, press release or any other public
disclosure listing the Investor as a purchaser of the Securities without the
Investor's prior written consent, except as may be required by applicable law or
rules of any exchange on which the Company's securities are listed.

7.

Notices.  All notices, requests, consents and other communications hereunder
shall be in writing, shall be delivered by first-class registered or certified
airmail, or nationally recognized overnight express courier, postage prepaid, or
by facsimile, and shall be deemed given (i) if delivered by first-class
registered or certified mail domestic, upon the business day received, (ii) if
delivered by nationally recognized overnight carrier, one business day after
timely delivery to such carrier, or (iii) if delivered by facsimile, upon
electric confirmation of receipt and shall be addressed as follows, or to such
other address or addresses as may have been furnished in writing by a party to
another party pursuant to this paragraph:

(a) if to the Company, to:

Diagnostic Imaging International Corporation

848 N. Rainbow Blvd. #2494

Las Vegas, Nevada  89107

Attention: Mr. Mitchell Geisler

Facsimile: (647) 288-1509

 

 

with a copy to:

Golenbock Eiseman Assor Bell & Peskoe LLP

437 Madison Avenue

New York, New York 10022

Attention: Andrew D. Hudders, Esq.

Facsimile: (212) 754-0330

(b)

if to the Investor, at its address on the signature page to the Securities
Purchase Agreement.

8.

Amendments; Waiver. This Agreement may not be modified or amended except
pursuant to an instrument in writing signed by the Company and the Investor. Any
waiver of a provision of this Agreement must be in writing and executed by the
party against whom enforcement of such waiver is sought.

9.

Headings. The headings of the various sections of this Agreement have been
inserted for convenience of reference only and shall not be deemed to be part of
this Agreement.

10.

Entire Agreement; Severability. This Agreement sets forth the entire agreement
and understanding of the parties relating to the subject matter hereof and
supersedes all prior and contemporaneous agreements, negotiations and
understandings between the parties, both oral and written relating to the
subject matter hereof. If any provision contained in this Agreement is
determined to be invalid, illegal or unenforceable in any respect, the validity,
legality and enforceability of the remaining provisions contained herein shall
not in any way be affected or impaired thereby.

11.

Governing Law; Jurisdiction.  This Agreement shall be governed by and construed
and enforced in accordance with the law of the State of New York, without giving
effect to principals of conflict of laws. The parties (i) agree that any legal
suit, action or proceeding arising out of or relating to this Agreement shall be
instituted exclusively in the courts of the State of New York, County of New
York, (ii) waive any objection to the venue of any such suit, action or
proceeding and the right to assert that such forum is not a convenient forum,
and (iii) irrevocably consent to the jurisdiction of the courts of the State of
New York, County of New York, in any such suit, action or proceeding, and
further agree to accept and acknowledge service of any and all process which may
be served in any such suit, action or proceeding and agree that service of
process upon them mailed by certified mail to their respective addresses shall
be deemed in every respect effective service of process upon them in any such
suit, action or proceeding.

4

--------------------------------------------------------------------------------

12.

Counterparts. This Agreement may be executed in two or more counterparts, each
of which shall constitute an original, but all of which, when taken together,
shall constitute but one instrument, and shall become effective when one or more
counterparts have been signed by each party hereto and delivered to the other
parties.

13.

Successors and Assigns.  This Agreement shall be binding upon and inure to the
benefit of the parties and their successors and permitted assigns. Neither party
may assign this Agreement or any rights or obligations hereunder without the
prior written consent of the other party (other than by merger).

14.

Fees and Expenses.  Each party shall pay the fees and expenses of its advisers,
counsel, accountants and other experts, if any, and all other expenses incurred
by such party incident to the negotiation, preparation, execution, delivery and
performance of this Agreement. The Company shall pay all transfer agent fees,
stamp taxes and other taxes and duties levied in connection with the delivery of
any Securities to the Investor.

15.

Severability.  If any term, provision, covenant or restriction of this Agreement
is held by a court of competent jurisdiction to be invalid, illegal, void or
unenforceable, the remainder of the terms, provisions, covenants and
restrictions set forth herein shall remain in full force and effect and shall in
no way be affected, impaired or invalidated, and the parties hereto shall use
their commercially reasonable efforts to find and employ an alternative means to
achieve the same or substantially the same result as that contemplated by such
term, provision, covenant or restriction.

16.

Remedies.  In addition to being entitled to exercise all rights provided herein
or granted by law, including recovery of damages, each of the Investor and the
Company will be entitled to specific performance under the Transaction
Documents.  The parties agree that monetary damages may not be adequate
compensation for any loss incurred by reason of any breach of obligations
contained in the Transaction Documents and hereby agrees to waive and not to
assert in any action for specific performance of any such obligation the defense
that a remedy at law would be adequate.

5

--------------------------------------------------------------------------------

EXHIBIT A

DIAGNOSTIC IMAGING INTERNATIONAL CORPORATION

CERTIFICATE QUESTIONNAIRE

Please provide us with the following information:

1.

The exact name in which your Note and Shares are to be registered. You may use a
nominee name if appropriate:

 

 

 

 

 

 

2.

If a nominee name is listed in response to Item 1 above, the relationship
between the Investor and such nominee:

 

 

 

 

 

 

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:

 

 

Note: If the registered holder does not have a Social Security or Tax
Identification Number, please provide a copy of the registered holder's
passport, or if an entity, a copy of the passport of one of the registered
holder's principals.

A-1

--------------------------------------------------------------------------------

EXHIBIT B

DIAGNOSTIC IMAGING INTERNATIONAL CORPORATION

FORM OF NOTE

Attached hereto.

B-1

--------------------------------------------------------------------------------

EXHIBIT C

DIAGNOSTIC IMAGING INTERNATIONAL CORPORATION

INVESTOR QUESTIONNAIRE

(All information will be treated confidentially)

To:

Diagnostic Imaging International Corporation

The undersigned hereby acknowledges the following:

This Investor Questionnaire ("Questionnaire") must be completed by a potential
investor in connection with the offer and sale of a Convertible Promissory Note
(the “Note”), and shares of Common Stock, par value $0.001 per share (“Shares”),
of Diagnostic Imaging International Corporation (the "Company"). The Note and
Shares (together the “Securities”) are being offered and sold by the Company
without registration under the Securities Act of 1933, as amended (the
"Securities Act"), and the securities laws of certain states, in reliance on the
exemptions contained in Section 4 of the Securities Act and on Regulation D
promulgated thereunder and in reliance on similar exemptions under applicable
state laws. The Company must determine that a potential investor meets certain
suitability requirements before offering or selling the Securities to such
investor. The purpose of this Questionnaire is to assure the Company that the
investor will meet the applicable suitability requirements. The information
supplied by the undersigned will be used in determining whether the undersigned
meets such criteria, and reliance upon the private offering exemption from
registration is based in part on the information herein supplied.

This Questionnaire does not constitute an offer to sell or a solicitation of an
offer to buy any security. The undersigned's answers will be kept strictly
confidential. However, by signing this Questionnaire the undersigned will be
authorizing the Company to provide a completed copy of this Questionnaire to
such parties as the Company deems appropriate in order to ensure that the offer
and sale of the Securities will not result in a violation of the Securities Act
or the securities laws of any state and that the undersigned otherwise satisfies
the suitability standards applicable to the investor of the Securities. All
potential investors must answer all applicable questions and complete, date and
sign this Questionnaire. The undersigned shall print or type its responses and
attach additional sheets of paper if necessary to complete its answers to any
item.

A.

Background Information

Name:

 

 

 

Business Address:

 

 

(Number and Street); (City) (State); (Zip Code)

 

 

Telephone Number:

 

 

 

Residence Address:

 

 

 

 

(Number and Street); (City) (State); (Zip Code)

Telephone Number:

 

Age: _________________

Citizenship:

___________________

Where registered to vote: ______________________

If a corporation, partnership, limited liability company, trust or other entity:

 

 

Type of entity:

 

State of formation:_____________________________

Date of formation::_____________________________

Social Security or Taxpayer Identification No.
__________________________________

Send all correspondence to (check one): _____Residence Address ____ Business
Address

B-2

--------------------------------------------------------------------------------

B.

Status as Accredited Investor

The undersigned is an "accredited investor" as such term is defined in
Regulation D under the Securities Act, because at the time of the sale of the
Shares the undersigned falls within one or more of the following categories
(Please initial one or more, as applicable):

_____ (1) a bank as defined in Section 3(a)(2) of the Securities Act, or a
savings and loan association or other institution as defined in Section
3(a)(5)(A) of the Securities Act whether acting in its individual or fiduciary
capacity; a broker or dealer registered pursuant to Section 15 of the Securities
Exchange Act of 1934; an insurance company as defined in Section 2(13) of the
Securities Act; an investment company registered under the Investment Company
Act of 1940 or a business development company as defined in Section 2(a)(48) of
that act; a Small Business Investment Company licensed by the U.S. Small
Business Administration under Section 301(c) or (d) of the Small Business
Investment Act of 1958; a plan established and maintained by a state, its
political subdivisions, or any agency or instrumentality of a state or its
political subdivisions for the benefit of its employees, if such plan has total
assets in excess of $5,000,000; an employee benefit plan within the meaning of
the Employee Retirement Income Security Act of 1974 if the investment decision
is made by a plan fiduciary, as defined in Section 3(21) of such act, which is
either a bank, savings and loan association, insurance company, or registered
investment adviser, or if the employee benefit plan has total assets in excess
of $5,000,000 or, if a self-directed plan, with the investment decisions made
solely by persons that are accredited investors;

_____ (2) a private business development company as defined in Section
202(a)(22) of the Investment Advisers Act of 1940;

_____ (3) an organization described in Section 501(c)(3) of the Internal Revenue
Code of 1986, as amended, as a corporation, Massachusetts or similar business
trust, or partnership, not formed for the specific purpose of acquiring the
Shares offered, with total assets in excess of $5,000,000;

_____ (4) a natural person whose individual net worth, or joint net worth with
that person's spouse, at the time of such person's purchase of the Shares
exceeds $1,000,000;

_____ (5) a natural person who had an individual income in excess of $200,000 in
each of the two most recent years or joint income with that person's spouse in
excess of $300,000 in each of those years and has a reasonable expectation of
reaching the same income level in the current year;

_____ (6) a trust, with total assets in excess of $5,000,000, not formed for the
specific purpose of acquiring the Shares offered, whose purchase is directed by
a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D; and

_____ (7) an entity in which all of the equity owners are accredited investors
(as defined above).

C.

Representations

The undersigned hereby represents and warrants to the Company as follows:

1.

Any purchase of the Securities would be solely for the account of the
undersigned and not for the account of any other person or with a view to any
resale, fractionalization, division, or distribution thereof.

2.

The information contained herein is complete and accurate and may be relied upon
by the Company, and the undersigned will notify the Company immediately of any
material change in any of such information occurring prior to the closing, if
any, with respect to the purchase of the Securities by the undersigned or any
co-Investor.

3.

There are no suits, pending litigation, or claims against the undersigned that
could materially affect the net worth of the undersigned as reported in this
Questionnaire.

B-3

--------------------------------------------------------------------------------

4.

The overall commitment of the undersigned to investments which are not readily
marketable is not excessive in view of the undersigned's net worth and financial
circumstances, and any purchase of the Securities will not cause such commitment
to become excessive. The undersigned is able to bear the economic risk of an
investment in the Securities.

5.

The undersigned has carefully considered the potential risks relating to the
Company and a purchase of the Securities and fully understands that the
Securities are speculative investments which involve a high degree of risk of
loss of the undersigned's entire investment.

6.

The following is a list of all states and other jurisdictions in which blue sky
or similar clearance will be required in connection with the undersigned's
purchase of the Securities:

________________________________________

________________________________________

________________________________________

The undersigned agrees to notify the Company in writing of any additional states
or other jurisdictions in which blue sky or similar clearance will be required
in connection with the undersigned's purchase of the Securities.

IN WITNESS WHEREOF, the undersigned has executed this Questionnaire this ____
day of __________, 2012, and declares under oath that it is truthful and
correct.

 

 

 

Investor Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investor Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

Title:

 

 

 

 

 

 

 

(required for an Investor that is a

corporation, partnership, trust or

other entity)

B-4