Exhibit 10.1

 

SECURITIES PURCHASE AGREEMENT

 

THIS SECURITIES PURCHASE AGREEMENT (the “Agreement”) is entered into as of
December 31, 2014, by and among DanDrit Biotech USA, Inc., a Delaware
corporation having an address of P.O. Box 189, Randolph, VT 05060 (the
“Company”) and the purchasers executing a signature page hereto (each,
individually, a “Purchaser” and collectively, the “Purchasers”).

 

R E C I T A L S

 

A.   The Company and each Purchaser are executing and delivering this Agreement
in reliance upon the exemption from securities registration afforded by
Regulation S (“Regulation S”) as promulgated by the United States Securities and
Exchange Commission (the “SEC”) under the Securities Act of 1933, as amended
(the “Securities Act”); and

 

B.   The parties desire that, upon the terms and subject to the conditions
contained herein, the Company shall issue and sell to the Purchasers, as
provided herein, and the Purchasers shall purchase, in the aggregate,
           shares (the “Shares”) of common stock, par value $0.0001 per share
(the “Common Stock”); in exchange for an aggregate purchase price of USD $
           (the “Offering”).

 

NOW, THEREFORE, in consideration of the mutual covenants and other agreements
contained in this Agreement, the Company and the Purchasers hereby agree as
follows:

 

SECTION 1

 

1.1   Subscription and Purchase of Shares. The Purchaser, intending to be
legally bound, hereby irrevocably subscribes for that number of Shares set forth
on such Purchaser’s signature page hereto (each, a “Subscription”) and
understands and acknowledges that the purchase price to be remitted to the
Company in exchange for such Purchaser’s Subscription shall be USD $5.00 per
share (each, such Purchaser’s respective “Purchase Price”). The undersigned
further understands and acknowledges that this Agreement is irrevocable.

 

1.2   Acceptance or Rejection of Subscription.

 

Payment of each Purchaser’s Purchase Price has been made simultaneous to the
execution of this Agreement by wire transfer as set forth below in full payment
for each Purchaser’s Subscription. The wire transfer instructions are as
follows:

 

Account Name: DanDrit Biotech USA Inc.

   

Bank: RBS Citizens Bank

FBO: Purchaser Name

Rt 12 A & Airport Rd, NH-439

  Social Security or

West Lebanon, NH, 03784, U.S.A.

  Passport Number

Routing #: 011 401 533

  Address

Account #: 331362 5225 SWIFT: CTZIUS33

   

 

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SECTION 2

 

2.1   Closing. The closing (the “Closing”) of the purchase and sale of the
Shares shall occur simultaneously with the acceptance by the Company of copies
of this Agreement executed by the Purchasers, as evidenced by the Company's
execution of this Agreement and receipt of each Purchaser’s Purchase Price. Each
Purchaser agrees that subject to the conditions set forth herein, the Company
will accept subscriptions and payments therefor as they are received. Such
Purchasers further understand that the Company will notify the Purchasers as to
whether their respective subscriptions have been accepted in whole or in part as
reasonably promptly as possible. If the Company accepts all or a portion of a
Purchaser’s subscription, such Purchaser agrees that this Agreement shall become
effective with respect to the Company and the Purchaser, and the Company will
promptly deliver to the Purchaser an executed copy of this Agreement and a
certificate representing the purchased Shares. Each Purchaser acknowledges that
the Company may terminate this Offering at any time.

 

In the event the sale of the Shares subscribed for by the Purchasers is not
consummated by the Company for any reason (in which event this Agreement shall
be deemed to be rejected), this Agreement and any other agreement entered into
between the Purchasers and the Company relating to this Agreement shall
thereafter have no force or effect and the Company shall promptly return or
cause to be returned to each Purchaser’s Purchase Price remitted to the Company
by the undersigned, without interest thereon or deduction therefrom, in exchange
for the Shares.

 

SECTION 3

 

3.1   Investor Representations and Warranties. Each Purchaser hereby
acknowledges, represents and warrants to, and agrees with, the Company and its
affiliates as follows:

 

(a)   Investment Purposes. Each Purchaser is acquiring the Shares for such
Purchaser’s own account as principal, not as a nominee or agent, for investment
purposes only, and not with a view to, or for, resale, distribution or
fractionalization thereof in whole or in part in any transactions that would be
in violation of the Securities Act or any state securities or “blue-sky” laws.
No other person has a direct or indirect beneficial interest in, and the
Purchaser does not have any contract, undertaking, agreement or arrangement with
any person to sell, transfer or grant participations to such person or to any
third person, with respect to, the Shares or any part of the Shares for which
the Purchaser is subscribing that would be in violation of the Securities Act or
any state securities or “blue-sky” laws.

 

(b)   Authority. Each Purchaser has full power and authority to enter into this
Agreement, the execution and delivery of this Agreement has been duly
authorized, if applicable, and this Agreement constitutes a valid and legally
binding obligation of the Purchaser.

 

(c)   Investment Experience. Each Purchaser, or such Purchaser’s professional
advisors, has such knowledge and experience in finance, securities, taxation,
investments and other business matters as to evaluate investments of the kind
described in this Agreement. By reason of the business and financial experience
of the undersigned or his professional advisors (who are not affiliated with or
compensated in any way by the Company or any of its affiliates or selling
agents), the Purchaser or such Purchaser’s advisors can protect the Purchaser’s
own interests in connection with the transactions described in this Agreement.
The Purchaser is able to afford the loss of his entire investment in the Shares.

 

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(d)   Exemption from Registration. Each Purchaser acknowledges such Purchaser’s
understanding that the offering and sale of the Shares is intended to be exempt
from registration under the Securities Act. In furtherance thereof, in addition
to the other representations and warranties of the Purchaser made herein, the
Purchaser further represents and warrants to and agrees with the Company and its
affiliates as follows:

 

(1)   The Purchaser has the financial ability to bear the substantial economic
risk of such Purchaser’s investment, has adequate means for providing for such
Purchaser’s current needs and personal contingencies and has no need for
liquidity with respect to Purchaser’s investment in the Company;

 

(2)   The Purchaser has such knowledge and experience in financial and business
matters as to be capable of evaluating the merits and risks of the prospective
investment in the Shares. The Purchaser also represents it has not been
organized for the purpose of acquiring the Shares; and

 

(3)   The Purchaser has been provided an opportunity for a reasonable period of
time prior to the date hereof to obtain additional information concerning the
offering of the Shares, the Company and all other information to the extent the
Company possesses such information or can acquire it without unreasonable effort
or expense.

 

(e)   Economic Considerations. The Purchaser is not relying on the Company, or
its affiliates or agents with respect to economic considerations involved in
this investment. The Purchaser has relied solely on its own advisors regarding
the investment, tax and legal merits and consequences of this agreement and the
Purchaser’s purchase of the Shares.

 

(f)   No Other Company Representations. No representations or warranties have
been made to the Purchaser by the Company, or any officer, employee, agent,
affiliate or subsidiary of the Company, other than the representations of the
Company contained herein, and in subscribing for Shares the Purchaser is not
relying upon any representations other than those contained herein.

 

(g)   Compliance with Laws. Any resale of the Shares during the “distribution
compliance period” as defined in Rule 902(f) to Regulation S shall only be made
in compliance with exemptions from registration afforded by Regulation S.
Further, any such sale of the Shares in any jurisdiction outside of the United
States will be made in compliance with the securities laws of such jurisdiction.
The Purchaser will not offer to sell or sell the Shares in any jurisdiction
unless the Purchaser obtains all required consents, if any.

 

(h)   Regulation S Exemption. The Purchaser understands that the Shares are
being offered and sold to such Purchaser in reliance on an exemption from the
registration requirements of United States federal and state securities laws
under Regulation S promulgated under the Securities Act and that the Company is
relying upon the truth and accuracy of the representations, warranties,
agreements, acknowledgments and understandings of the Purchaser set forth herein
in order to determine the applicability of such exemptions and the suitability
of the Purchaser to acquire the Shares. In this regard, the Purchaser
represents, warrants and agrees that:

 

(1)    The Purchaser is not a U.S. Person (as defined below) and is not an
affiliate (as defined in Rule 501(b) under the Securities Act) of the Company
and is not acquiring the Shares for the account or benefit of a U.S. Person. A
U.S. Person means any one of the following:

 

(A)   any natural person resident in the United States of America or U.S.
citizen;

 

(B)   any partnership or corporation organized or incorporated under the laws of
the United States of America;

 

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(C)   any estate of which any executor or administrator is a U.S. person;

 

(D)   any trust of which any trustee is a U.S. person;

 

(E)   any agency or branch of a foreign entity located in the United States of
America;

 

(F)   any non-discretionary account or similar account (other than an estate or
trust) held by a dealer or other fiduciary for the benefit or account of a U.S.
person;

 

(G)   any discretionary account or similar account (other than an estate or
trust) held by a dealer or other fiduciary organized, incorporated or (if an
individual) resident in the United States of America; and

 

(H)   any partnership or corporation if:

 

(i)    organized or incorporated under the laws of any foreign jurisdiction; and

 

(ii)   formed by a U.S. person principally for the purpose of investing in
securities not registered under the Securities Act, unless it is organized or
incorporated, and owned, by accredited investors (as defined in Rule 501(a)
under the Securities Act) who are not natural persons, estates or trusts.

 

(2)   At the time of the origination of contact concerning this Agreement and
the date of the execution and delivery of this Agreement, the Purchaser was
outside of the United States.

 

(3)   The Purchaser will not, during the period commencing on the date of
issuance of the Shares and ending on the six month anniversary of the Closing or
such other period as may otherwise be applicable in accordance with the terms
and conditions of Regulation S or other applicable securities law (the
“Restricted Period”), offer, sell, pledge or otherwise transfer the Shares in
the United States, or to a U.S. Person for the account or for the benefit of a
U.S. Person, or otherwise in a manner that is not in compliance with Regulation
S.

 

(4)   The Purchaser will, after expiration of the Restricted Period, offer,
sell, pledge or otherwise transfer the Shares only pursuant to registration
under the Securities Act or an available exemption therefrom and, in accordance
with all applicable state and foreign securities laws.

 

(5)   The Purchaser was not in the United States, engaged in, and prior to the
expiration of the Restricted Period will not engage in, any short selling of or
any hedging transaction with respect to the Shares, including without
limitation, any put, call or other option transaction, option writing or equity
swap.

 

(6)   Neither the Purchaser nor or any person acting on such Purchaser’s behalf
has engaged, nor will engage, in any directed selling efforts to a U.S. Person
with respect to the Shares and the Purchaser and any person acting on such
Purchaser’s behalf have complied and will comply with the “offering
restrictions” requirements of Regulation S under the Securities Act.

 

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(7)   The transactions contemplated by this Agreement have not been pre-arranged
with a buyer located in the United States or with a U.S. Person, and are not
part of a plan or scheme to evade the registration requirements of the
Securities Act.

 

(8)   Neither the Purchaser nor any person acting on his behalf has undertaken
or carried out any activity for the purpose of, or that could reasonably be
expected to have the effect of, conditioning the market in the United States,
its territories or possessions, for any of the Shares. The Purchaser agrees not
to cause any advertisement of the Shares to be published in any newspaper or
periodical or posted in any public place and not to issue any circular relating
to the Shares, except such advertisements that include the statements required
by Regulation S under the Securities Act, and only offshore and not in the U.S.
or its territories, and only in compliance with any local applicable securities
laws.

 

(9)   Each certificate representing the Shares shall be endorsed with the
following legends, in addition to any other legend required to be placed thereon
by applicable federal or state securities laws:

 

(A)   “THE SECURITIES ARE BEING OFFERED TO INVESTORS WHO ARE NOT U.S. PERSONS
(AS DEFINED IN REGULATION S UNDER THE SECURITIES ACT OF 1933, AS AMENDED (“THE
SECURITIES ACT”)) AND WITHOUT REGISTRATION WITH THE UNITED STATES SECURITIES AND
EXCHANGE COMMISSION UNDER THE SECURITIES ACT IN RELIANCE UPON REGULATION S
PROMULGATED UNDER THE SECURITIES ACT.”

 

(B)   “TRANSFER OF THESE SECURITIES IS PROHIBITED, EXCEPT IN ACCORDANCE WITH THE
PROVISIONS OF REGULATION S, PURSUANT TO REGISTRATION UNDER THE SECURITIES ACT,
OR PURSUANT TO AVAILABLE EXEMPTION FROM REGISTRATION. HEDGING TRANSACTIONS MAY
NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE SECURITIES ACT.”

 

(10)    The Purchaser consents to the Company making a notation on its records
or giving instructions to any transfer agent of the Company in order to
implement the restrictions on transfer of the Shares set forth in this Section
2.

 

      (i)   No Registration; Regulation S. Purchaser has been advised and
acknowledges: (i) that the Shares have not been, and when issued, will not be
registered under the Securities Act, the securities laws of any state of the
United States or the securities laws of any other country; (ii) that in issuing
and selling the Shares to Purchaser, the Company is relying upon the “safe
harbor” provided by Regulation S and/or on Section 4(a)(2) under the Act; (iii)
that it is a condition to the availability of the Regulation S safe harbor that
the Shares not be offered or sold in the United States or to a U.S. Person until
the expiration of the Restricted Period; (iv) that, notwithstanding the
foregoing, during the Restricted Period the Shares may be offered and sold by
the holder thereof only if such offer and sale is made in compliance with the
terms of this Agreement and either: (A) if the offer or sale is within the
United States or to or for the account of a U.S. Person (as such terms are
defined in Regulation S), the Shares are offered and sold pursuant to an
effective registration statement or pursuant to Rule 144 under the Securities
Act or pursuant to an exemption from the registration requirements of the
Securities Act; or (B) the offer and sale is outside the United States and is
not made to a U.S. Person.

 

(j)   No Directed Selling. The Purchaser has not engaged, nor is it aware that
any party has engaged, and the Purchaser will not engage or cause any third
party to engage in any “directed selling” efforts (as such term is defined in
Regulation S) in the United States with respect to the Shares. Specifically, the
Purchaser has not taken any action for purposes of, or could have the effect of,
conditioning the market or arousing interest for the Shares in the United
States, and the Purchaser has not placed any advertisements in any publication
or made any public announcement in any publication in the United States
regarding the offering of the Shares.

 

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(k)   Receipt of Information. The Purchaser has carefully reviewed all of the
Company’s filings under the Securities Exchange Act of 1934, as amended (the
“Exchange Act”) and understands that the risks inherent with an investment in
the Company. The Purchaser has received all documents, records, books and other
information pertaining to the Purchaser’s investment in the Company that has
been requested by the Purchaser.

 

(l)   No Governmental Review. The Purchaser is aware that no federal or state
agency has (i) made any finding or determination as to the fairness of this
investment, (ii) made any recommendation or endorsement of the Shares or the
Company, or (iii) guaranteed or insured any investment in the Shares or any
investment made by the Company.

 

(m)   Price of Shares. The Purchaser understands that the price of the Shares
offered hereby was determined by the Company without reference to the assets or
book value of the Company. The Purchaser further understands that there is a
substantial risk of further dilution of such Purchaser’s investment in the
Company.

 

(n)   Investor Questionnaire. Each Purchaser has executed and delivered a copy
of the Investor Questionnaire attached hereto as Exhibit A.

 

(o)   No Broker. The Purchaser represents and warrants that the Purchaser has
not engaged, consented to nor authorized any broker, finder or intermediary to
act on such Purchaser’s behalf, directly or indirectly, as a broker, finder or
intermediary in connection with the transactions contemplated by this Agreement.

 

SECTION 4

 

4.1   Company’s Representations and Warranties. The Company represents and
warrants to the undersigned as follows:

 

(a)   Organization of the Company. The Company is a corporation duly organized
and validly existing and in good standing under the laws of the State of
Delaware.

 

(b)   Authority. (a) The Company has the requisite corporate power and authority
to enter into and perform its obligations under this Agreement and to issue the
Shares; (b) the execution and delivery of this Agreement by the Company and the
consummation by it of the transactions contemplated hereby and thereby have been
duly authorized by all necessary corporate action and no further consent or
authorization of the Company or its Board of Directors or stockholders is
required; and (c) this Agreement has been duly executed and delivered by the
Company and constitutes a valid and binding obligation of the Company
enforceable against the Company in accordance with its terms, except as such
enforceability may be limited by applicable bankruptcy, insolvency, or similar
laws relating to, or affecting generally the enforcement of, creditors' rights
and remedies or by other equitable principles of general application.

 

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(c)   Exemption from Registration; Valid Issuances. The sale and issuance of the
Shares, in accordance with the terms and on the bases of the representations and
warranties of the Purchasers set forth herein, may and shall be properly issued
by the Company to the Purchasers pursuant to any applicable federal or state
law. When issued and paid for as herein provided, the Shares shall be duly and
validly issued, fully paid, and nonassessable. Neither the sales of the Shares
pursuant to, nor the Company's performance of its obligations under, this
Agreement shall result in the creation or imposition of any liens, charges,
claims or other encumbrances upon the Shares or any of the assets of the
Company. The Shares shall not subject the Purchasers to personal liability by
reason of the ownership thereof.

 

(d)   Private Placement; No Integrated Offering. Subject to the accuracy of the
Purchasers’ representations and warranties in Section 2 of this Agreement, the
offer and sale by the Company of the Shares in conformity with the terms of this
Agreement constitute transactions that are exempt from registration under the
Securities Act. None of the Company, its subsidiaries, any of their affiliates,
and any person acting on their behalf has, directly or indirectly, made any
offers or sales of any security or solicited any offers to buy any security,
under circumstances that would require registration of any of the Shares under
the Securities Act or cause this Offering of the Shares to be integrated with
prior offerings by the Company for purposes of the Securities Act or any
applicable stockholder approval provisions, including, without limitation, under
the rules and regulations of any exchange or automated quotation system on which
any of the securities of the Company are listed or designated. None of the
Company, its subsidiaries, their affiliates and any person acting on their
behalf will take any action or steps referred to in the preceding sentence that
would require registration of any of the Shares under the Securities Act or
cause the Offering of the Shares to be integrated with other offerings.

 

SECTION 5

 

5.1  Indemnity. Each Purchaser agrees to indemnify and hold harmless the
Company, its officers and directors, employees and its affiliates and their
respective successors and assigns and each other person, if any, who controls
any thereof, against any loss, liability, claim, damage and expense whatsoever
(including, but not limited to, any and all expenses whatsoever reasonably
incurred in investigating, preparing or defending against any litigation
commenced or threatened or any claim whatsoever) arising out of or based upon
any false representation or warranty or breach or failure by the undersigned to
comply with any covenant or agreement made by such Purchaser herein or in any
other document furnished by the undersigned to any of the foregoing in
connection with this transaction.

 

5.2   Modification. Neither this Agreement nor any provisions hereof shall be
modified, discharged or terminated except by an instrument in writing signed by
the party against whom any waiver, change, discharge or termination is sought.

 

5.3   Notices. Any notice, demand or other communication which any party hereto
may be required, or may elect, to give to anyone interested hereunder shall be
sufficiently given if (a) deposited, postage prepaid, in a United States mail
letter box, registered or certified mail, return receipt requested, addressed to
such address as may be given herein, (b) delivered personally at such address,
(c) upon the expiration of twenty four (24) hours after transmission, if sent by
facsimile if a confirmation of transmission is produced by the sending machine
(and a copy of each facsimile promptly shall be sent by ordinary mail), (d) upon
the expiration of twenty four (24) hours after transmission, if sent by email if
a confirmation of transmission is produced by the sending computer (and a copy
of each email transmission promptly shall be sent by ordinary mail) or (e) on
the third business day, if sent by overnight recognized courier, in each case to
the parties at their respective addresses set forth below their signatures to
this Agreement (or at such other address for a party as shall be specified by
like notice; provided that the notices of a change of address shall be effective
only upon receipt thereof).

 

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5.4   Counterparts. This Agreement may be executed through the use of separate
signature pages or in any number of counterparts and by facsimile or other
electronic means, and each of such counterparts shall, for all purposes,
constitute one agreement binding on all parties, notwithstanding that all
parties are not signatories to the same counterpart.

 

5.5   Binding Effect. Except as otherwise provided herein, this Agreement shall
be binding upon and inure to the benefit of the parties and their heirs,
executors, administrators, successors, legal representatives and assigns. If the
Purchase is more than one person, the obligation of the Purchaser shall be joint
and several and the agreements, representations, warranties and acknowledgments
herein contained shall be deemed to be made by and be binding upon each such
person and his heirs, executors, administrators and successors.

 

5.6   Entire Agreement. This Agreement and the documents referenced herein
contain the entire agreement of the parties and there are no representations,
covenants or other agreements except as stated or referred to herein and
therein.

 

5.7   Assignability. This Agreement is not transferable or assignable by the
undersigned.

 

5.8   Applicable Law; Arbitration; Jurisdiction. This Agreement shall be
governed by and construed in accordance with the laws of the State of Delaware
without giving effect to conflicts of law principles. Any dispute between or,
action or proceeding against any of the parties hereto under, arising out of or
in any manner relating to, this Agreement and the transactions contemplated
herein shall be submitted to and adjudicated by binding arbitration under the
rules of the American Arbitration Association (“AAA”). Such arbitration shall be
in New York, New York. If there is any litigation regarding the arbitration or
otherwise relating to this section 5.8, the parties hereto irrevocably consent
to the jurisdiction of the courts of the State of New York and of any federal
court located in such State in connection with any action or proceeding arising
out of or relating to this Agreement, any document or instrument delivered
pursuant to, in connection with or simultaneously with this Agreement, or a
breach of this Agreement or any such document or instrument. In any such action
or proceeding, each party hereto waives personal service of any summons,
complaint or other process and agrees that service thereof may be made in
accordance with Section 5.3. Within 30 days after such service, or such other
time as may be mutually agreed upon in writing by the attorneys for the parties
to such action or proceeding, the party so served shall appear or answer such
summons, complaint or other process. EACH PARTY HERETO WAIVES TRIAL BY JURY IN
ANY ACTION, SUIT OR PROCEEDING ARISING OUT OF THIS AGREEMENT OR ANY BREACH OR
ALLEGED BREACH HEREOF.

 

5.9   Pronouns. The use herein of the masculine pronouns "him" or "his" or
similar terms shall be deemed to include the feminine and neuter genders as well
and the use herein of the singular pronoun shall be deemed to include the plural
as well.

 

5.10 Further Assurances. Upon request from time to time, each Purchaser shall
execute and deliver all documents and do all other acts that may be necessary or
desirable, in the reasonable opinion of the Company or its counsel, to effect
the subscription for the Shares in accordance herewith.

 

[Remainder of Page Intentionally Omitted; Signature Pages to Follow]

 

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IN WITNESS WHEREOF, the parties hereto have executed this Securities Purchase
Agreement as of the day and year this subscription has been accepted by the
Company as set forth below.

 

Number of Shares    

 

Purchase Price Per Share: $ 5.00           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: ___________, 2014 

   

INVESTOR NAME

(Exactly as shall be printed on a certificate representing the Shares)

 

By:    

 

Print Name:    

 

Title:    

 

SSN/Passport Number/Taxpayer
Identification Number:    

 

Address:                

 

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SUBSCRIPTION AGREEMENT

 

Agreed and Accepted _________, 2014

 

DanDrit Biotech USA, Inc.

 

By:       Name: Dr. Eric Leire     Title: Chief Executive Officer  

 

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EXHIBIT A

 

INVESTOR QUESTIONNAIRE

 

(All Information Will Be Treated Confidentially)

 

INSTRUCTIONS

 

This document is intended for a selected group of prospective investors in
DanDrit Biotech USA, Inc., a Delaware corporation (“Company”). The primary
purpose of this Investor Questionnaire (this “Questionnaire”), to be completed
and provided by each Purchaser, is to elicit information sufficient to permit
the Company to reasonably conclude that the Purchaser has sufficient investment
sophistication, ability to take financial risk associated with the investment,
meet the Company’s investment standards and requirements, and meet the
requirements of U.S. federal, state and certain other applicable securities
laws.

 

If the answer to any question is “None” or “Not Applicable,” please so state.

 

YOUR ANSWERS WILL AT ALL TIMES BE KEPT STRICTLY CONFIDENTIAL. EACH PERSON
COMPLETING AND SIGNING THIS QUESTIONNAIRE AGREES, HOWEVER, THAT COMPANY
MANAGEMENT MAY PRESENT THIS QUESTIONNAIRE TO SUCH PARTIES AS MANAGEMENT DEEMS
APPROPRIATE IF CALLED ON TO RESPOND TO INQUIRIES, OR ESTABLISH COMPLIANCE WITH
THE U.S. SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”) OR ANY OTHER SECURITIES
LAWS, OR IN CONNECTION WITH COMPLIANCE WITH ANY OTHER APPLICABLE LAW, RULE OR
REGULATION (INCLUDING, WITHOUT LIMITATION, THE U.S. PATRIOT ACT, THE FOREIGN
CORRUPT PRACTICES ACT, AND ANTI-MONEY LAUNDERING LAWS, RULES AND REGULATIONS).

 

A.       IDENTIFYING INFORMATION

 

Full Name(s):

 

Business Address:   Home Address:

 

   

 

                            Business Phone   Home Phone       Business E-mail  
Home E-mail     Business Facsimile   Home Facsimile

 

          Date of Birth   Marital Status   Number of Dependents

 

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Country of Citizenship: ______   Personal Identification # _____________

 

Entity Identification #: N/A________________   Tax ID
Number/SSN:N/A_____________________

 

In what country (and province therein, if applicable) is the Purchaser’s
principal residence?

 

Singapore    

 

If the Purchaser has resided in the above country (and province therein if
applicable) for less than one year, or plans to change the Purchaser’s principal
residence, please explain:

 

                 

 

Is there any reason the Purchaser might be considered a resident of another
country (and state therein if applicable) (e.g., live part of the year, have an
office or business, registered to vote, pay taxes or hold a driver’s license in
another jurisdiction)? If so, please explain:

 

                 

 

B.       INVESTMENT BACKGROUND AND OBJECTIVES

 

Approximate number of years the Purchaser has been investing:    _______________

 

Please indicate the frequency of the Purchaser’s investments in
small-capitalization equity securities:

 

  ☐  often ☐  occasionally ☐  seldom ☐  never

 

Mutual funds and private securities investment pools:

 

  ☐  often ☐  occasionally ☐  seldom ☐  never

 

Marketable securities (stocks, options, derivatives, bonds, debentures, notes):

 

  ☐  often ☐  occasionally ☐  seldom ☐  never

 

Privately held corporations, limited liability companies and partnerships and
start-up ventures (stocks, bonds, debentures, notes, member or partnership
interests):

 

  ☐  often ☐  occasionally ☐  seldom ☐  never

 

12

 

 

Change in Amounts Invested. Is the total amount of the Purchaser’s investment in
this Offering currently substantially more than the total amount that the
Purchaser has typically invested overall, in the past several years (other than
as the result of market increases)? Yes ☐          No ☐

 

If yes, please give details (e.g., when did increase occur, what was approximate
value of total prior portfolio):

 

     

 

Knowledge and Experience. The Purchaser has such knowledge and experience in
financial and business matters that the Purchaser is capable of evaluating the
merits and risks of an investment in the Company [check one]: Yes ☐          No
☐

 

C.         NON-U.S. PERSONS

 

The undersigned is requested to initial each paragraph below that applies to the
Purchaser. By initialing each respective paragraph below, the Purchaser hereby
indicates Purchaser’s agreement to be bound by each such covenant appearing
below, and hereby states that the following representations and acknowledgements
are true and correct as indicated below:

 

___  

The undersigned is over the age of 18, and is qualified to make the
representations in this document.

 

___  

Purchaser is a legal resident of the jurisdiction indicated as the country of
“principal residence” as indicated in Part A above in this Questionnaire, over
the past 90 days.

 

___  

Purchaser’s place of residence is outside of the United States.

 

___  

Purchaser is investing in Shares of the Company solely for Subscriber’s own
account, and not on behalf of or for the account of any other person.

 

___  

Purchaser will not acquire the Shares for the account or benefit of any U.S.
Person (as defined below).

 

___  

At the time of subscription and purchase of the Shares, Purchaser will be
located outside the United States.

 

 

13

 

 

___  

Purchaser is not currently, and when Purchaser acquires the Shares, Purchaser
will not be, any of the following (a “U.S. Person”):

 

-          a natural person residing in the United States;

-          a partnership or corporation organized or incorporated under the laws
of the United States;

-          an estate of which any executor or administrator is a U.S. Person;

-          a trust of which any trustee is a U.S. Person;

-          an agency or branch of a foreign entity located in the United States;

-          a non-discretionary account or similar account (other than an estate
or trust) held by a dealer or other fiduciary for the benefit or account of a
U.S. Person;

-          a discretionary account or similar account (other than an estate or
trust) held by a dealer or other fiduciary organized, incorporated, or (if an
individual) resident in the United States; or

-          a partnership or corporation organized or incorporated under the laws
of any foreign jurisdiction, that has been is formed by a U.S. Person.

 

___  

Purchaser has been advised, and acknowledges that:

 

-          the Shares have not been registered under the U.S. Securities Act of
1933 (“Act”), the securities laws of any state of the United States or the
securities laws of any other country;

-          in conducting a transaction involving issuance of the Shares to the
undersigned, the Company is and will be relying upon the “safe harbor” provided
by Regulation S under the Act;

-          it is a condition to the availability of the Regulation S safe harbor
that the Shares will not be re-offered or re-sold in the United States or to a
U.S. Person until the expiration of a period of six (6) months following the
date of receipt of the Shares (“Restricted Period”);

-          during the Restricted Period the Shares may be offered and sold by
the holder only if such offer and sale is made in compliance with Regulation S
and other U.S. securities laws, and either:

-          if the offer or sale is within the United States or to or for the
account of a U.S. Person (as such terms are defined in Regulation S), the
securities are offered and sold pursuant to an effective registration statement
or pursuant to Rule 144 under the Act or pursuant to an exemption from the
registration requirements of the Act; or

-          the offer and sale is outside the United States and is not made to a
U.S. Person.

 

___  

Purchaser has not engaged, nor is Purchaser aware that any party has engaged,
and Purchaser will not engage or cause any third party to engage, in any
“directed selling” efforts (as such term is defined in Regulation S) in the
United States with respect to the Shares. Specifically, the undersigned has not
taken any action for purposes of, or could have the effect of, conditioning the
market or arousing interest for the Shares in the United States. The undersigned
has not placed any advertisements in any publication or made any public
announcement in any publication in the United States regarding any offering of
the Shares.

 

___  

Purchaser is not a “distributor” of securities. The Purchaser nor any affiliate,
representative or agent acting on Purchaser’s behalf is a “dealer” as such term
is defined in the Act. Specifically, the Purchaser does not intend to act as a
distributor or dealer of the Shares. The Purchaser has not entered into any
agreement to distribute the Shares. The Purchaser is not in the business of
buying, selling, trading or brokering securities on behalf of others.

 

 

14

 

 

___  

The Purchaser hereby represents that Purchaser has complied with all local laws
applicable to the undersigned, for the acquisition of the Shares, including:

-          the legal requirements of my jurisdiction for the purchase and
acquisition of the Shares,

-          any foreign exchange restrictions applicable to such purchase and
acquisition,

-          any governmental or other consents that may need to be obtained, and

-          the transfer, income tax and other tax regulations, if any, which may
be relevant to the purchase, holding, redemption, sale, or transfer of the
Shares.

 

___  

The Purchaser’s subscription, purchase, acquisition and payment for (as
applicable), and the Purchaser’s continued ownership of the Shares will not
violate any applicable securities or other laws of the Purchaser’s home
jurisdiction (i.e. the country or jurisdiction of residence and/or domicile of
the Purchaser).

 

___  

The Purchaser understands that the certificates or other instruments
representing the Shares shall bear restrictive legends as required under U.S.
securities laws, and this legend will effectively restrict transfer of the
Shares.

 

___  

The Purchaser understands that hedging activities may not be conducted with
respect to the Shares unless in compliance with the Act.

 

___  

If the Purchaser is an entity, (i) the undersigned entity is domiciled in the
jurisdiction specified below its address on the signature page of this document,
or the address of record for the entity last provided in writing to the Company;
(ii) the undersigned entity is a validly existing corporation, limited
partnership, or limited liability company (or similar entity) and has all
requisite corporate, partnership or limited liability company power and/or
similar authority to acquire in the Shares.

 

___  

The Purchaser reasonably believes that the above representations will remain
true and accurate at the time when the Purchaser receives the Shares.

 

___   The Purchaser agrees to promptly notify the Company immediately in the
event that any of the above statements becomes untrue or inaccurate, for a
period of up to ninety (90) days after the undersigned has executed and
delivered this Questionnaire.  

 

15

 

 

SUBSCRIPTION AMOUNT

 

Please complete the following information regarding your subscription:

 

  Shares Subscribed for:           Subscription Amount: USD $

 

 

 
Exact Name Purchaser would like to appear in Transfer Agent Records for Company
Common Stock Indicate ownership as:

 

  ____ (a) Individual     ____ (b) Community Property     ____ (c) Joint Tenants
with Right of Survivorship ) All parties   ____ (d) Tenants in Common ) must
sign   ____ (e) Corporate     ____ (f) Partnership     ____ (g) Trust  

 

D.         SIGNATURE

 

To the best knowledge and belief of the undersigned, the above information is
true and correct in all respects. The undersigned agrees to notify the Company
in writing immediately of any material change in any of the foregoing
information prior to the consummation of a purchase of securities, and any
change in the information in Part A at any time in the future so long as the
Purchaser is a holder of the securities sold by the Company.

 

[Signature Page Follows]

 

16

 

 

The undersigned understands that the information being furnished in this
Questionnaire is required primarily to enable the Company and its management to
determine whether an offer and sale of Shares to the Purchaser may be made in
compliance with applicable laws including U.S. federal and state securities
laws.

 

Date: ____, 2014     Name of Purchaser           Signature           Name of
Signatory           Title (if applicable)

 

 

 

17