Exhibit 10.1

SUBSCRIPTION AGREEMENT

 

 

1. The Parties. THIS SUBSCRIPTION AGREEMENT (this “Agreement”) is entered into
effective as of the      day of              2014, by and between PURE
BIOSCIENCE, INC., a Delaware corporation (alternatively referred to herein as
the “Issuer” or the “Company”), and the purchaser identified on Exhibit “A”,
attached hereto and incorporated herein by reference (the “Purchaser”). The
Company and the Purchaser are sometimes referred to collectively herein as the
“Parties”, and each individually as a “Party”.

2. Recitals. The Parties acknowledge and understand that the Company is
currently offering for sale $2,300,000 worth of shares of its Common Stock, $.01
par value per share (the “Shares”), having the rights, privileges, and
preferences as set forth in the Certificate of Incorporation of the Company (the
“Certificate”). This offering is made pursuant to detailed financial and due
diligence information and documentation previously delivered or made available
through the Company’s public filings at www.sec.gov to the Purchaser, the
receipt of which is hereby acknowledged (the “Due Diligence Information”). The
Parties further understand that the offering is being made without registration
of the Shares under the Securities Act of 1933, as amended (the “Securities
Act”), and is being made to the Purchaser in its capacity as an “accredited
investor” (as defined in Rule 501 of Regulation D under the Securities Act).

3. Subscription. Subject to the terms and conditions hereof, the Purchaser
hereby irrevocably subscribes for that number of Shares referenced on Exhibit
“A” (the “Purchased Shares”), at the purchase price per Share also referenced on
Exhibit “A”, for the total purchase price also referenced on Exhibit “A”. The
purchase price is payable in accordance with Section 6, below. The Parties
acknowledge that the Shares will be subject to restrictions on transfer pursuant
to other agreements which may be executed by and between the Parties, and as
further set forth in this Agreement.

4. Acceptance of Subscription and Issuance of Shares. It is understood and
agreed that the Company shall have the sole right, at its complete discretion,
to accept or reject this subscription, in whole or in part, for any reason and
that the same shall be deemed to be accepted by the Company only when it is
signed by a duly authorized officer of the Company and delivered to the
Purchaser at the Closing referred to in Section 5 hereof. Notwithstanding
anything in this Agreement to the contrary, the Company shall have no obligation
to issue any of the Shares to any person who is a resident of a jurisdiction in
which the issuance of Shares to it would constitute a violation of the
securities, “blue sky” or other similar laws of such jurisdiction (collectively
referred to as the “State Securities Laws”).

5. Closing and Closing Date. The closing of the purchase and sale of the Shares
(the “Closing”) shall take place at the offices of the Company, on the day
designated by the Company (the “Closing Date”), or at such place as the Parties
may agree.

6. Payment for Shares. Payment for the Shares shall be received by the Company
from the Purchaser by check, cashier’s check or wire transfer of immediately
available funds at or prior to the Closing. As soon as practicable after the
Closing the Company shall deliver to the Purchaser a certificate for the
Purchased Shares.

7. Representations and Warranties of the Company. As of the Closing, the Company
represents and warrants that:

(a) The Company is duly incorporated, validly existing and in good standing
under the laws of the State of Delaware, with full power and authority to
conduct its business as it is currently being conducted and to own its assets
and has secured any other authorizations, approvals, permits and orders required
by law for the conduct by the Company of its business as it is currently being
conducted.

 

1

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

(b) The Company has duly authorized the issuance and sale of the Purchased
Shares upon the terms of their offer by all requisite corporate action. The
Company has reserved for issuance such number of Shares.

(c) The Purchased Shares, when issued and paid for, will represent validly
authorized, duly issued and fully paid and nonassessable Shares of the Company,
and the issuance thereof will not conflict with the certificate of incorporation
or bylaws of the Company nor with any outstanding warrant, option, call,
preemptive right or commitment of any type relating to the Company’s capital
stock. The Purchased Shares shall have the rights, preferences and privileges
set forth in the Certificate.

(d) No representation or warranty by the Company in this Agreement, and no
statement by an officer of the Company contained in any document, certificate or
other writing furnished to the Purchaser in connection with the transactions
contemplated hereby, when taken as a whole, contains any untrue statement of a
material fact or omits to state any material fact necessary to make statements
herein or therein not misleading in light of the circumstances in which they are
made.

(e) The Company has filed all reports, schedules, forms, statements and other
documents required to be filed by the Company under applicable federal
securities laws (collectively referred to herein as the “SEC Reports”).

(f) As of the Closing, the consummation by the Company of the transactions
herein contemplated, including the execution, delivery and consummation of this
Agreement, will comply with all applicable law and will not:

(1) Violate any judgment, statute, law, code, act, order, writ, rule, ordinance,
regulation, governmental consent or governmental requirement, or determination
or decree of any arbitrator, court, or other governmental agency or
administrative body, which now or at any time hereafter may be applicable to and
enforceable against the relevant party, work, or activity in question or any
part thereof (collectively, “Requirement of Law”) applicable to or binding upon
the Company or any of its assets;

(2) Violate (i) the terms of the Certificate or Bylaws of the Company; or,
(ii) any material agreement, contract, mortgage, indenture, bond, bill, note, or
other material instrument or writing binding upon the Company or to which the
Company is subject; or

(3) Result in the breach of, constitute a default under, constitute an event
which with notice or lapse of time, or both, would become a default under, or
result in the creation of any lien, security interest, charge or encumbrance
upon any of the assets or other properties of the Company under any agreement,
commitment, contract (written or oral) or other instrument to which the Company
is a party, or by which the assets or other properties of the Company are bound
or affected.

 

  8. Representations and Warranties of the Purchaser. The Purchaser hereby
represents and warrants that:

8.1 General.

(a) The Purchaser has all requisite authority to enter into this Agreement and
to perform all the obligations required to be performed by the Purchaser
hereunder.

(b) The Purchaser is a resident of the state (or, was formed in the state, as
appropriate) referenced on Exhibit “A”.

 

2

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

(c) The Purchaser is not acquiring the Purchased Shares as an agent or otherwise
for any other person.

(d) As of the Closing, the consummation by the Purchaser of the transactions
herein contemplated, including the execution, delivery and consummation of this
Agreement, will not violate any Requirement of Law applicable to or binding upon
the Purchaser.

8.2 Information Concerning the Company.

(a) The Purchaser has received a copy of the Due Diligence Information. The
Purchaser has not been furnished any offering literature other than the Due
Diligence Information, and the Purchaser has exclusively relied only on the
information contained therein and in the SEC Reports.

(b) The Purchaser is familiar with the business and financial condition,
properties, operations, and prospects of the Company, and that there are no
guarantees of the success of the Company. The Purchaser has been given the
opportunity to obtain any information necessary to verify the accuracy of the
information set forth in the Due Diligence Information and in the SEC Reports
and has been furnished all such information so requested.

(c) The Purchaser understands that, unless it notifies the Company in writing to
the contrary at or before the Closing, all of the representations and warranties
contained in Section 8 of this Agreement will be deemed true and correct as of
the Closing by the Purchaser in all respect with the same effect as thought made
on closing taking into account all information received by purchaser from the
Company.

(d) The Purchaser understands that the purchase of the Purchased Shares involves
various risks, including those outlined in the SEC Reports.

(e) The Purchaser understands that no federal or state agency has passed upon
the Purchased Shares or made any finding or determination concerning the
fairness or advisability of this investment.

(f) The Purchaser understands that estimates and projections like those
contained in the Due Diligence Information, by their nature, involve significant
elements of subjective judgment and analysis that may or may not be correct;
that there can be no assurance that such projections or goals will be attained;
and, that the projections and estimates contained in the Due Diligence
Information should not be relied upon as a promise or representation of the
future performance of the Company.

8.3 Accredited Investor Status.

(a) The Purchaser is an “accredited investor” as defined in Rule 501(a) under
Regulation D of the Securities Act. The Purchaser agrees to furnish any
additional information requested to assure compliance with applicable federal
and state securities laws in connection with the purchase and sale of the
Shares, and further acknowledges that it has completed the Accredited Investor
Questionnaire, attached hereto as Exhibit “B”, and that the information
contained therein is complete and accurate as of the date thereof and is hereby
affirmed as of the date of the Closing.

(b) The Purchaser has such knowledge, skill, and experience in business,
financial and investment matters so that it is capable of evaluating the merits
and risks of an investment in the Purchased Shares. To the extent necessary, it
has retained, at its own expense, and relied upon, appropriate professional
advice regarding the investment, tax and legal merits and consequences of this
Agreement and owning the Purchased Shares.

 

3

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

8.4 Purchase Transaction and Restrictions on Transfer or Sale of the Shares.

(a) The Purchaser is acquiring the Purchased Shares solely for its own
beneficial account, for investment purposes, and not with a view to, or for
resale in connection with, any distribution of the Purchased Shares. The
Purchaser understands that the Purchased Shares have not been registered under
the Securities Act or any State Securities Laws by reason of specific exemptions
under the provisions thereof which depend in part upon the investment intent of
the Purchaser and of the other representations made by the Purchaser in this
Agreement. The Purchaser understands that the Company is relying upon the
representations and agreements contained in this Agreement (and any supplemental
information) for the purpose of determining whether this transaction meets the
requirements for such exemptions.

(b) As of the Closing the Purchaser will be purchasing the Purchased Shares
based upon its own independent investigation and evaluation of the Company and
its prospects, and the covenants, representations, and warranties of the Company
set forth herein. The Purchaser is expressly not relying on any oral
representations made by the Company or any of its agents.

(c) The Purchaser understands that the Purchased Shares are “restricted
securities” under applicable federal securities laws and that the Securities Act
and the rules of the Securities and Exchange Commission (the “Commission”)
provide in substance that the Purchaser may dispose of the Purchased Shares only
pursuant to an effective registration statement under the Securities Act or an
exemption therefrom (including Rule 144 under the Securities Act). Purchaser is
aware of the provisions of Rule 144 promulgated under the Securities Act which
permit limited resale of shares purchased in a private placement subject to the
satisfaction of certain conditions, including among other things, the existence
of a public market for the shares, the availability of certain current public
information about the Company, the resale occurring not less than six-months
after a party has purchased and paid for the security to be sold, the sale being
effected through a “broker’s transaction” or in transactions directly with a
“market marker” and the number of shares being sold during any three-month
period not exceeding specified limitations. Purchaser acknowledges that, in the
event all of the requirements of Rule 144 are not met, registration under the
Securities Act or an alternative exemption from registration will be required
for any disposition of the Purchased Shares. As a consequence, the Purchaser
understands that it must bear the economic risks of the investment in the
Purchased Shares for an indeterminate period of time.

(d) The Purchaser has not offered or sold any portion of the Purchased Shares
and has no present intention of dividing the Purchased Shares with others or of
reselling or otherwise disposing of any portion of the Purchased Shares either
currently or after the passage of a fixed or determinable period of time or upon
the occurrence or nonoccurrence of any predetermined event or circumstance.

(e) The Purchaser acknowledges that neither the Company nor any other person
offered to sell the Purchased Shares to it by means of any form of general
advertising, such as media advertising or seminars.

(f) The Purchaser has not used any person as a “purchaser representative” within
the meaning of SEC Regulation D to represent it in determining whether it should
purchase the Shares, unless otherwise specifically disclosed to, and
acknowledged by, the Company in writing.

 

4

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

9. Obligations Irrevocable. The obligations of the Purchaser to effect the
purchase hereunder shall be irrevocable, except in the event of a breach of a
material provision of this Agreement by the Company or abandonment by the
Company pursuant to Section 8.4(h).

10. Legend. Each certificate for Purchased Shares will be imprinted with a
legend in substantially the following form:

“THE SECURITIES REPRESENTED BY THIS INSTRUMENT HAVE NOT BEEN REGISTERED UNDER
THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR ANY STATE
SECURITIES LAWS, AND MAY NOT BE SOLD OR TRANSFERRED OR OFFERED FOR SALE OR
TRANSFER UNLESS A REGISTRATION STATEMENT UNDER THE SECURITIES ACT AND OTHER
APPLICABLE SECURITIES LAWS WITH RESPECT TO SUCH SECURITIES IS THEN IN EFFECT, OR
IN THE OPINION OF COUNSEL, SUCH REGISTRATION UNDER THE SECURITIES ACT AND OTHER
APPLICABLE SECURITIES LAWS IS NOT REQUIRED.”

11. Brokers. The Purchaser has not entered into any agreement to pay any
broker’s or finder’s fee to any Person with respect to this Agreement or the
transactions contemplated hereby. In the sole discretion of the Company it may
retain brokers and finders, the payment which, if any, will be the sole
responsibility of the Company.

12. Left Intentionally Blank

13. Additional Provisions.

13.1 Executed Counterparts. This Agreement may be executed in any number of
counterparts, all of which when taken together shall be considered one and the
same agreement, it being understood that all Parties need not sign the same
counterpart. In the event that any signature is delivered by fax or by e-mail
delivery of a “.pdf” format data file, such signature shall create a valid and
binding obligation of the Party executing (or on whose behalf such signature is
executed) with the same force and effect as if such facsimile or “.pdf”
signature page were an original thereof. Each of the Parties hereby expressly
forever waives any and all rights to raise the use of a fax machine or E-Mail to
deliver a signature, or the fact that any signature or agreement or instrument
was transmitted or communicated through the use of a fax machine or E-Mail, as a
defense to the formation of a contract.

13.2 Successors and Assigns. Except as expressly provided in this Agreement,
each and all of the covenants, terms, provisions, conditions and agreements
herein contained shall be binding upon and shall inure to the benefit of the
successors and assigns of the Parties hereto.

13.3 Article and Section Headings. The article and section headings used in this
Agreement are inserted for convenience and identification only and are not to be
used in any manner to interpret this Agreement.

13.4 Severability. Each and every provision of this Agreement is severable and
independent of any other term or provision of this Agreement. If any term or
provision hereof is held void or invalid for any reason by a court of competent
jurisdiction, such invalidity shall not affect the remainder of this Agreement.

13.5 Governing Law. This Agreement shall be governed by the laws of the State of
Delaware, without giving effect to any choice or conflict of law provision or
rule (whether of the State of Delaware or any other jurisdiction) that would
cause the application of the laws of any jurisdiction other than the State of
Delaware. The laws of the State of Delaware shall only apply to the extent
necessary to comply with such law in light of the fact that the Company is a
Delaware corporation. Each Party agrees that all legal proceedings concerning
the interpretations, enforcement and defense of the transactions contemplated

 

5

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

by this Agreement (whether brought against a Party or its respective affiliates,
directors, officers, shareholders, employees or agents) shall be commenced
exclusively in the state and federal courts sitting in the County of San Diego.
Each Party hereby irrevocably submits to the exclusive jurisdiction of the state
and federal courts sitting in the County of San Diego, State of California, for
the adjudication of any dispute hereunder or in connection herewith or with any
transaction contemplated hereby or discussed herein, and hereby irrevocably
waives, and agrees not to assert in any suit, action or proceeding, any claim
that it is not personally subject to the jurisdiction of any such court, that
such suit, action or proceeding is improper or is an inconvenient venue for such
proceeding.

13.6 Entire Agreement. This Agreement, and all references, documents, or
instruments referred to herein, contains the entire agreement and understanding
of the Parties hereto in respect to the subject matter contained herein. The
Parties have expressly not relied upon any promises, representations,
warranties, agreements, covenants, or undertakings, other than those expressly
set forth or referred to herein. This Agreement supersedes any and all prior
written or oral agreements, understandings, and negotiations between the Parties
with respect to the subject matter contained herein.

13.7 Additional Documentation. The Parties hereto agree to execute, acknowledge,
and cause to be filed and recorded, if necessary, any and all documents,
amendments, notices, and certificates which may be necessary or convenient under
the laws of the State of Delaware.

13.8 Attorney’s Fees. If any legal action (including arbitration) is necessary
to enforce the terms and conditions of this Agreement, the prevailing Party
after final judgment shall be entitled to costs and reasonable attorney’s fees.

13.9 Amendment. This Agreement may be amended or modified only by a writing
signed by all Parties.

13.10 Remedies.

(a) Specific Performance. The Parties hereby declare that it is impossible to
measure in money the damages which will result from a failure to perform any of
the obligations under this Agreement. Therefore, each Party waives the claim or
defense that an adequate remedy at law exists in any action or proceeding
brought to enforce the provisions hereof.

(b) Cumulative. The remedies of the Parties under this Agreement are cumulative
and shall not exclude any other remedies to which any person may be lawfully
entitled.

13.11 Waiver. No failure by any Party to insist on the strict performance of any
covenant, duty, agreement, or condition of this Agreement or to exercise any
right or remedy on a breach shall constitute a waiver of any such breach or of
any other covenant, duty, agreement, or condition.

13.12 Assignability. This Agreement is not assignable by either Party without
the expressed written consent of all other Parties.

13.13 Notices.

(a) Method and Delivery. All notices, requests and demands hereunder shall be in
writing and delivered by hand, by Electronic Transmission, by mail, by telegram,
or by recognized commercial over-night delivery service (such as Federal
Express, UPS, or DHL), and shall be deemed given (a) if by hand delivery, upon
such delivery; (b) if by Electronic Transmission, upon telephone confirmation of
receipt of same; (c) if by mail, forty-eight (48) hours after deposit in the
United States mail, first class, registered or certified mail, postage prepaid;
(d) if by telegram, upon telephone confirmation of receipt of same; or, (e) if
by recognized commercial over-night delivery service, upon such delivery.

 

6

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

(b) Consent to Electronic Transmissions. Each Party hereby expressly consents to
the use of Electronic Transmissions for communications and notices under this
Agreement. For purposes of this Agreement, “Electronic Transmissions” means a
communication (i) delivered by facsimile telecommunication or electronic mail
when directed to the facsimile number or electronic mail address, respectively,
for that recipient on record with the sending Party; and, (ii) that creates a
record that is capable of retention, retrieval, and review, and that may
thereafter be rendered into clearly legible tangible form.

13.14 Time. All Parties agree that time is of the essence as to this Agreement.

13.15 Provision Not Construed Against Party Drafting Agreement. This Agreement
is the result of negotiations by and between the Parties, and each Party has had
the opportunity to be represented by independent legal counsel of its choice.
This Agreement is the product of the work and efforts of all Parties, and shall
be deemed to have been drafted by all Parties. In the event of a dispute, no
Party hereto shall be entitled to claim that any provision should be construed
against any other Party by reason of the fact that it was drafted by one
particular Party.

13.16 Incorporation of Exhibits and Schedules. The Exhibits and Schedules
identified in this Agreement are incorporated herein by reference and made a
part hereof as if set out in full herein.

13.17 Recitals. The facts recited in Section 2, above, are hereby conclusively
presumed to be true as between and affecting the Parties.

13.18 Consents, Approvals, and Discretion. Except as herein expressly provided
to the contrary, whenever this Agreement requires consent or approval to be
given by a Party, or a Party must or may exercise discretion, the Parties agree
that such consent or approval shall not be unreasonably withheld, conditioned,
or delayed, and such discretion shall be reasonably exercised. Except as
otherwise provided herein, if no response to a consent or request for approval
is provided within ten (10) days from the receipt of the request, then the
consent or approval shall be presumed to have been given.

13.19 Best Efforts. The Parties shall use and exercise their best efforts,
taking all reasonable, ordinary and necessary measures to ensure an orderly and
smooth relationship under this Agreement, and further agree to work together and
negotiate in good faith to resolve any differences or problems which may arise
in the future.

13.20 Definitional Provisions. For purposes of this Agreement, (i) those words,
names, or terms which are specifically defined herein shall have the meaning
specifically ascribed to them; (ii) wherever from the context it appears
appropriate, each term stated either in the singular or plural shall include the
singular and plural; (iii) wherever from the context it appears appropriate, the
masculine, feminine, or neuter gender, shall each include the others; (iv) the
words “hereof”, “herein”, “hereunder”, and words of similar import, when used in
this Agreement, shall refer to this Agreement as a whole, and not to any
particular provision of this Agreement; (v) all references to designated
“Articles”, “Sections”, and to other subdivisions are to the designated
Articles, Sections, and other subdivisions of this Agreement as originally
executed; (vi) all references to “Dollars” or “$” shall be construed as being
United States dollars; (vii) the term “including” is not limiting and means
“including without limitation”; and, (viii) all references to all statutes,
statutory provisions, regulations, or similar administrative provisions shall be
construed as a reference to such statute, statutory provision, regulation, or
similar administrative provision as in force at the date of this Agreement and
as may be subsequently amended.

 

7

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

****SIGNATURES APPEAR ON NEXT PAGE****

 

8

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

EXHIBIT “A”

PURCHASER INFORMATION AND EXECUTION

The Purchaser hereby subscribes for such number of shares of Stock as set forth
below and agrees to be bound by the terms and conditions of this Agreement.

 

1.   Purchaser Name:   

 

   2.   Purchaser’s Contact Info:            Address:   

 

          

 

          

 

        E-Mail:   

 

        Phone:   

 

        Fax:   

 

   3.   Purchase Price Per Share:    One Dollar ($1.00)    4.   Number of Shares
Purchased:   

 

   5.   Total Purchase Price:   

 

  

 

 

    

 

Signature of Purchaser      Signature of Joint Purchaser (and title, if
applicable)      (if any)

 

    

 

Taxpayer Identification or Social Security Number      Taxpayer Identification
or Social Security Number of Joint Purchaser (if any)

 

DATED:

 

 

    

 

DATED:

 

 

Name as it should appear on Stock Certificate:

 

 

 

ACCEPTED BY:

PURE BIOSCIENCE, INC.,

a Delaware corporation

By:  

 

NAME:   Peter C. Wulff TITLE:   CFO & COO DATED:  

 

 

9

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

EXHIBIT “B”

ACCREDITED INVESTOR QUESTIONNAIRE

1. IF YOU ARE AN INDIVIDUAL PLEASE FILL IN THE IDENTIFICATION QUESTIONS IN (A).
IF YOU ARE AN ENTITY PLEASE FILL IN THE IDENTIFICATION QUESTIONS IN (B)

 

  A. IDENTIFICATION QUESTIONS FOR INDIVIDUALS

 

Name:  

 

  Residence Address:  

 

  Date of Birth:  

 

  Social Security Number:  

 

 

 

  B. IDENTIFICATION QUESTIONS FOR ENTITIES

 

Name:  

 

Address of Principal Place of Business:  

 

 

Type of Entity (corporation, partnership, trust, etc.):  

 

State (or Country) of Formation or Incorporation:  

 

Contact Person:  

 

Telephone Number:  

 

Was entity formed for the purpose of this investment? Yes     No     

2. DESCRIPTION OF INVESTOR

The following information is required to ascertain whether you would be deemed
an “accredited investor” as defined in Rule 501 of Regulation D under the
Securities Act. Please check whether you are any of the following:

¨ a corporation or partnership with total assets in excess of $5,000,000, not
organized for the purpose of this particular investment;

¨ private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940 [a U.S. venture capital fund which invests
primarily through private placements in non-publicly traded securities and makes
available (either directly or through co-investors) to the portfolio companies
significant guidance concerning management, operations or business objectives];

¨ 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;

¨ 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 trust not organized to make this particular investment, with total assets in
excess of $5,000,000 whose purchase is directed by a sophisticated person as
described in Rule 506(b)(2)(ii) of the Securities Act of 1933 and who completed
item 4 below of this questionnaire;

¨ a bank as defined in Section 3(a)(2) or a savings and loan association or
other institution defined in Section 3(a)(5)(A) of the Securities Act of 1933
acting in either an individual or fiduciary capacity;

¨ an insurance company as defined in Section 2(13) of the Securities Act of
1933;

 

10

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

¨ an employee benefit plan within the meaning of Title I of the Employee
Retirement Income Security Act of 1974 (i) whose investment decision is made by
a fiduciary which is either a bank, savings and loan association, insurance
company, or registered investment advisor, or (ii) whose total assets exceed
$5,000,000, or (iii) if a self-directed plan, whose investment decisions are
made solely by a person who is an accredited investor and who completed Part I
of this questionnaire;

¨ a charitable, religious, educational, or other organization described in
Section 501(c)(3) of the Internal Revenue Code, not formed for the purpose of
this investment, with total assets in excess of $5,000,000;

¨ an entity not located in the U.S. none of whose equity owners are U.S.
citizens or U.S. residents;

¨ a plan having assets exceeding $5,000,000 established and maintained by a
government agency for its employees;

¨ an individual who had individual income from all sources during each of the
last two years in excess of $200,000 or the joint income of you and your spouse
(if married) from all sources during each of such years in excess of $300,000,
and who reasonably expects that either your own income from all sources during
the current year to exceed $200,000 or the joint income of you and your spouse
(if married) from all sources during the current year to exceed $300,000;

¨ an individual whose net worth as of the date you purchase the securities
offered, together with the net worth of your spouse, be in excess of $1,000,000;
or

¨ an entity in which all of the equity owners are accredited investors.

3. BUSINESS, INVESTMENT, AND EDUCATIONAL EXPERIENCE

 

Occupation:  

 

  Number of Years:  

 

  Present Employer:  

 

  Position/Title:  

 

  Educational Background:  

 

 

Frequency of prior investment (check one in each appropriate column):

 

     Stocks & Bonds    Venture Capital Investments Frequently       Occasionally
      Never      

4. SIGNATURE:

The above information is true and correct of my own knowledge. The undersigned
recognizes that the Company and its counsel are relying on the truth and
accuracy of such information in reliance on the exemption contained in
Subsection 4(2) of the Securities Act of 1933, as amended, and Regulation D
promulgated thereunder. The undersigned agrees to notify the Company promptly of
any changes in the foregoing information which may occur prior to Closing.

Executed at                     , State of                     , on the      day
of             , 2014.

 

 

(Signature),                     (Title if for Entity)

 

11