Exhibit 10.04

 

LONG BLOCKCHAIN CORP.

 

Subscription Agreement

 

 

 

 

INSTRUCTIONS

 

IMPORTANT: PLEASE READ CAREFULLY BEFORE SIGNING. SIGNIFICANT

OBLIGATIONS AND REPRESENTATIONS ARE CONTAINED IN THIS DOCUMENT.

 

Steps For All Investors

 

1. Fill in your name and amount of investment on Page 3.

 

Additional Steps for Individual Investors

 

1. Complete the requested information on Page 8. 2. Sign Page 10.

 

Additional Steps for Entity Investors

 

1. Complete the requested information on Page 9. 2. Sign Page 10. 3. If
applicable, complete the information on Pages 11 and please sign as indicated
thereon.

 

PLEASE DELIVER TWO EXECUTED COPIES OF THE SUBSCRIPTION AGREEMENT TO:

 

Long Blockchain Corp.

12-1 Dubon Court

Farmingdale, NY 11735

 

THE SUBSCRIPTION PAYMENT MUST BE WIRED AS FOLLOWS:

 

Wire your funds to the following account, maintained by Long Blockchain Corp.:

 

Bank Info: Metroplitan Commercial Bank

Bank Address: 1359 Broadway, New York, NY 10018

Routing No.: 026013356

Account Name: Long Blockchain Corp.

Account No.: 0499008405

 

When you wire your funds, please notify Shamyl Malik at 855-452-5222.

 

Any questions you may have concerning these documents or the payment of your
subscription amount should be directed to Shamyl Malik at 855-452-5222

 

 

 

 

Print Name of Investor: _________________________

 

SUBSCRIPTION AGREEMENT

 

This Subscription Agreement (“Subscription Agreement”) is being used by Long
Blockchain Corp., a Delaware corporation (the “Company”), for a private
placement (the “Offering”) of shares (the “Shares”) of the Company’s common
stock, par value $0.0001 per share (“Common Stock”), at a price of $0.40 per
Share on the terms contained in this Subscription Agreement. In addition,
Investor will receive a warrant in the form of Exhibit A hereto (the “Warrant”)
to purchase a number of shares of Common Stock equal to 30% of the Shares
purchased hereunder (the “Warrant Shares”). The Shares, Warrant and Warrant
Shares are sometimes referred to herein, collectively, as the “Securities.”

 

The above-named Investor hereby agrees as follows:

 

1. Subscription for Securities. Investor hereby subscribes for and agrees to
purchase $600,000.00 of Shares of the Company at a purchase price of $0.40 per
Share, subject to the terms and conditions set forth in this Subscription
Agreement. In addition, the Company will issue to Investor a Warrant to purchase
a number of Warrant Shares equal to 30% of the Shares purchased hereunder.

 

2. Offering. The Shares, Warrant and Warrants Shares are being offered in a
private placement in accordance with the terms set forth in this Subscription
Agreement.

 

3. Investor Delivery of Documents and Payment. Investor has tendered to the
Company two (2) completed and manually executed copies of this Subscription
Agreement. Simultaneously with submitting this Subscription Agreement, the
Investor is wiring the subscription amount in accordance with the directions on
the cover sheet (or delivering evidence of any outstanding loans or advances
being converted in this Offering).

 

4. Acceptance or Rejection of Subscription; Return of Unapplied Funds. The
Company has the right to reject this subscription, in whole or in part, for any
reason and at any time prior to a Closing (defined below). In the event of the
rejection of this subscription, my subscription payment will be promptly
returned to me without interest or deduction and this Subscription Agreement
shall have no force or effect. The Shares subscribed for herein and the Warrant
will not be deemed issued to or owned by the Investor until one copy of this
Subscription Agreement has been executed by the Investor and countersigned by
the Company and the Closing (defined below) with respect to the Investor’s
subscription has occurred.

 

5. Closing and Delivery of Securities. The Offering is being made on a “no
minimum, no maximum, best efforts” basis. The closing (“Closing”) on an
Investor’s investment may occur at any time, as determined by the Company,
together with, or separate from, investments by other Investors. The Company may
accept this Subscription Agreement and have a Closing for all or any portion of
the Shares subscribed for and for all or a corresponding portion of the Warrant
by executing a copy hereof as provided and notifying Investor of such
acceptance.

 

6. Offering to Accredited Investors. The Offering is limited to “accredited
investors” as defined in Section 2(15) of the Securities Act of 1933, as amended
(“Securities Act”), and Rule 501(a) promulgated thereunder, and is being made
without registration under the Securities Act in reliance upon the exemptions
contained in Section 4(a)(2) of the Securities Act and applicable state
securities laws, it being understood that for purposes of the qualifying under
the $1,000,000 net worth test in the definition of accredited investor:

 

  ● The Investor’s primary residence shall not be included as an asset;   ●
Indebtedness that is secured by the Investor’s primary residence, up to the
estimated fair market value of the primary residence as of the date of this
Agreement, shall not be included as a liability (except that if the amount of
such indebtedness outstanding as of such date exceeds the amount outstanding 60
days before such date, other than as a result of the acquisition of the primary
residence, the amount of such excess shall be included as a liability); and

 

2

 

 

  ● Indebtedness that is secured by the Investor’s primary residence in excess
of the estimated fair market value of the primary residence shall be included as
a liability.

 

7. Investor Representations and Warranties.

 

7.1. No Right to Terminate. Investor is aware that Investor is not entitled to
cancel, terminate or revoke this subscription, and any agreements made in
connection herewith will survive an individual Investor’s death or disability.
In order to induce the Company to issue and sell Securities to Investor,
Investor represents and warrants that the information relating to Investor
stated herein is true and complete as of the date hereof and will be true and
complete as of the date or dates on which Investor’s purchase of Securities
becomes effective. If, prior to the final consummation of the offer and sale of
the Securities, there should be any change in such information or any of such
information becomes incorrect or incomplete, Investor agrees to notify the
Company and supply the Company promptly with corrective information.

 

7.2. Information About the Company and the Securities.

 

(a) The Company has made available to Investor a copy of the Company’s Annual
Report on Form 10-K for the fiscal year ended December 31, 2017 and the
Company’s Quarterly Reports on Form 10-Q and Current Reports on Form 8-K filed
since such date, as well as the other filings made by the Company pursuant to
Section 13(a) of the Securities Exchange Act of 1934, as amended, as of the
execution date of this Subscription Agreement (together the “Disclosure
Documents”). Investor has read the Disclosure Documents, including the “Risk
Factors” set forth in the Annual Report on Form 10-K, together with this
Subscription Agreement, and fully understands the information set forth therein
and herein.

 

(b) Investor has been given access to full and complete information regarding
the Company as Investor has requested and has utilized such access to Investor’s
satisfaction for the purpose of verifying the information included herein and
therein, and Investor has either met with or been given reasonable opportunity
to meet with the individuals who will become the officers of the Company for the
purpose of asking reasonable questions of such officers concerning the terms and
conditions of the Offering and the business of the Company and all such
questions have been answered to Investor’s full satisfaction. Investor has also
been given an opportunity to obtain any additional relevant information to the
extent reasonably available to the Company. After reading of such information
and materials, Investor understands that there is no assurance as to the future
performance of the Securities.

 

(c) Investor has received no representation or warranty from the Company or any
of its officers, directors, equity holders, employees or agents in respect of
Investor’s investment in the Securities. Investor is not participating in the
Offering as a result of or subsequent to: (i) any advertisement, article, notice
or other communication published in any newspaper, magazine or similar media or
broadcast over television, radio or the Internet or (ii) any seminar or meeting
whose attendees have been invited by any general solicitation or general
advertising.

 

7.3. Speculative Investment. Investor is aware that the Securities are a
speculative investment that involve a high degree of risk and Investor may
suffer the total loss of its investment. Investor has such knowledge and
experience in financial and business matters as to be capable of evaluating the
merits and risks of an investment in the Securities and have obtained, in
Investor’s judgment, sufficient information to evaluate the merits and risks of
an investment in the Securities. Investor has not utilized any person as its
purchaser representative (as defined in Regulation D) in connection with
evaluating such merits and risks and has relied solely upon its own
investigation in making a decision to invest in the Securities. Investor has
been urged to seek independent advice from its professional advisors relating to
the suitability of an investment in the Securities in view of its overall
financial needs and with respect to the legal and tax implications of such
investment. Investor believes that the investment in the Securities is suitable
for it based upon its investment objectives and financial needs, and Investor
has adequate means for providing for its current financial needs and
contingencies and has no need for liquidity with respect to its investment in
the Securities. The investment in the Securities does not constitute a
significant portion of Investor’s investment portfolio.

 

3

 

 

7.4. Restrictions on Transfer. Investor understands that (i) the Securities have
not been registered under the Securities Act or the securities laws of certain
states in reliance on specific exemptions from registration and (ii) the
Securities cannot be resold, pledged, assigned or otherwise disposed of unless
they are subsequently registered under the Securities Act and under applicable
securities laws of certain states, or an exemption from such registration is
available. Each certificate representing the Securities will bear a restrictive
legend relating to such restrictions. In addition, Investor understands that (x)
no securities administrator of any state or the federal government has
recommended or endorsed the Offering or made any finding or determination
relating to the fairness of an investment in the Securities and (y) the Company
is relying on Investor’s representations and agreements for the purpose of
determining whether this transaction meets the requirements of the exemptions
afforded by the Securities Act and certain state securities laws. Investor
understands that the Company is under no obligation to register the Securities,
except as expressly set forth herein, or to assist Investor in complying with
any exemption from such registration under the Securities Act or any state
securities laws

 

7.5. Investment Representation. Investor is purchasing the Securities for its
own account for investment and not with a view to, or for sale in connection
with, any subsequent distribution of the securities, nor with any present
intention of selling or otherwise disposing of all or any part of the Securities
in violation of the Federal securities laws.

 

7.6. Entity Authority. If Investor is a corporation, partnership, company,
trust, employee benefit plan, individual retirement account, Keogh plan or other
tax-exempt entity, it is authorized and qualified to become an investor in the
Securities and the person signing this Subscription Agreement on behalf of such
entity has been duly authorized by such entity to do so.

 

7.7. No Offer Until Determination of Suitability. Investor acknowledges that any
delivery to Investor of the documents relating to the Offering prior to the
determination by the Company of Investor’s suitability will not constitute an
offer of the Securities until such determination of suitability is made.

 

7.8. For Florida Residents. The Securities have not been registered under the
Securities Act of 1933, as amended (“1933 Act”), or the Florida Securities and
Investor Protection Act (“Florida Securities Act”), by reason of specific
exemptions thereunder relating to the limited availability of the Offering. The
Securities cannot be sold, transferred or otherwise disposed of to any person or
entity unless subsequently registered under the 1933 Act or the Florida
Securities Act, if such registration is required. Pursuant to Section
517.061(11) of the Florida Securities Act, when sales are made to five (5) or
more persons in Florida, any sale made pursuant to Subsection 517.061(11) of the
Florida Securities Act will be voidable by such Florida purchaser either within
three (3) days after the first tender of consideration is made by the purchaser
to the issuer, an agent of the issuer, or an escrow agent, or within three (3)
days after the availability of the privilege is communicated to such purchaser,
whichever occurs later. In addition, as required by Section 517.061(11)(a)(3) of
the Florida Securities Act and by Rule 69W-500.005(5)(a) thereunder, if Investor
is a Florida resident Investor may have, at the offices of the Company, at any
reasonable hour, after reasonable notice, access to the materials set forth in
such Rule that the Company can obtain without unreasonable effort or expense.

 

8. Intentionally Omitted.

 

4

 

 

9. Indemnification. Investor hereby agrees to indemnify and hold harmless the
Company, its officers, directors, shareholders, employees, agents and attorneys
against any and all losses, claims, demands, liabilities, and expenses
(including reasonable legal or other expenses incurred by each such person in
connection with defending or investigating any such claims or liabilities,
whether or not resulting in any liability to such person or whether incurred by
the indemnified party in any action or proceeding between the indemnitor and
indemnified party or between the indemnified party and any third party) to which
any such indemnified party may become subject, insofar as such losses, claims,
demands, liabilities and expenses (a) arise out of or are based upon any untrue
statement or alleged untrue statement of a material fact made by Investor and
contained herein or (b) arise out of or are based upon any breach by Investor of
any representation, warranty or agreement made by Investor contained herein.

 

10. Severability; Remedies. In the event any part or parts of this Subscription
Agreement are found to be void, the remaining provisions of this Subscription
Agreement are nevertheless binding with the same effect as though the void part
or parts were deleted.

 

11. Governing Law. This Agreement shall be governed by and construed in
accordance with the law of the State of Delaware regardless of the law that
might otherwise govern under applicable principles of conflicts of law thereof.

 

12. Counterparts. This Subscription Agreement may be executed in one or more
counterparts, each of which will be deemed an original but all of which together
will constitute one and the same instrument. The execution of this Subscription
Agreement may be by actual or facsimile signature.

 

13. Benefit. Except as otherwise set forth herein, this Subscription Agreement
is binding upon and inures to the benefit of the parties hereto and their
respective heirs, executors, personal representatives, successors and assigns.

 

14. Notices. All notices, offers, acceptance and any other acts under this
Subscription Agreement (except payment) must be in writing, and is sufficiently
given if delivered to the addressees in person, by overnight courier service,
facsimile, electronic transmission (including via email) or, if mailed, postage
prepaid, by certified mail (return receipt requested), and will be effective
three days after being placed in the mail if mailed, or upon receipt or refusal
of receipt, if delivered personally or by courier or confirmed telecopy or other
electronic transmission (including via email), in each case addressed to a
party. All communications to Investor should be sent to Investor’s address on
the signature page hereto. All communications to the Company should be sent to:

 

LONG BLOCKCHAIN CORP.
12-1 Dubon Court
Farmingdale, NY 11735
Attention: Shamyl Malik
Telephone: 855-452-5222
Email: shamyl.malik@longblockchain.com

 

15. Oral Evidence. This Subscription Agreement constitutes the entire agreement
between the parties with respect to the subject matter hereof and supersedes all
prior oral and written agreements between the parties hereto with respect to the
subject matter hereof. This Subscription Agreement may not be changed, waived,
discharged, or terminated orally, but rather, only by a statement in writing
signed by the party or parties against which enforcement or the change, waiver,
discharge or termination is sought.

 

16. Paragraph Headings. Paragraph headings herein have been inserted for
reference only and will not be deemed to limit or otherwise affect, in any
matter, or be deemed to interpret in whole or in part, any of the terms or
provisions of this Subscription Agreement.

 

17. Survival of Representations, Warranties and Agreements. The representations,
warranties and agreements contained herein will survive the delivery of, and the
payment for, the Securities.

 

[QUESTIONNAIRES AND SIGNATURE PAGES FOLLOW]

 

5

 

 

INDIVIDUAL and JOINT INVESTORS – Complete All Information

 

Additional information may be requested

 

Investor’s Name:             Date of Birth:   SSN/Tax ID:            
Co-Investor Name:           Date of Birth:   SSN/Tax ID:            
Home Street Address:           City:   State:     Zip Code:          
Mailing Street Address:           City:   State:     Zip Code:          
Work Phone:   Home Phone:           E-Mail Address:  

 

Do you believe you have sufficient knowledge and experience in financial and
business matters to evaluate the merits and risks of the Securities?      [  ]
Yes      [  ] No

 

Are you familiar with the risk aspects and the non-liquidity of investments such
as the securities for which you seek to subscribe?       [  ] Yes       [  ] No

 

Investment Objectives (Please select one): [  ] Speculation [  ] Growth [  ]
Income [  ] Capital Preservation

 

Investor’s Information: Employer:
____________________________________________________________

 

Title: _______________________________      Type of Business:
__________________________________

 

Employer’s Address:
______________________________________________________________________

 

Income: Expected 2018: ______________ Actual 2017: ______________ Actual 2016:
____________________

 

Net Worth: ________________________ Total Value of Investments:
________________________________

 

Co-Investor’s Information: Employer:
_________________________________________________________

 

Title: _______________________________ Type of Business:
____________________________________

 

Employer’s Address:
______________________________________________________________________

 

Income: Expected 2018: ______________ Actual 2017: ______________ Actual 2016:
____________________

 

Net Worth: ________________________ Total Value of Investments:
_______________________________

 

 

 

 

ENTITY INFORMATION – Complete All Information

 

Additional information may be requested

 

Entity  Name:             Tax ID:    State of Formation:             Company
Street Address:           City:   State:     Zip Code:           Primary
Contact:   Title:           Telephone Number:   Fax Number:          
Email Address:  

 

Do you believe your officers, directors, employees, trustees or equity owners
have sufficient knowledge and experience in financial and business matters to
evaluate the merits and risks of the Securities?

[  ] Yes                    [  ] No

 

Are you familiar with the risk aspects and the non-liquidity of investments such
as the securities for which you seek to subscribe? [  ] Yes
                  [  ] No

 

Investment Objectives (Please select one): [  ] Speculation [  ] Growth [  ]
Income [  ] Capital Preservation

 

 

 

 

ALL MUST COMPLETE

 

Accredited Investor Status*:

 

Please check one or more of the following definitions of “accredited investor,”
if any, which applies to you. If none of the following applies to you, you may
not qualify to take parting this offering.

 

[  ] A Bank as defined in Section 3(a)(2) of the Act, or any savings association
or institution as defined in Section 3(a)(5)(A) of the Securities Act of 1933,
as amended (the “Act”).     [  ] Any broker or dealer registered pursuant to
Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange
Act”).     [  ] An insurance company as defined in Section 2(13) of the Act.    
[  ] Investment company registered under the Investment Company Act of 1940, as
amended (the “Investment Company Act”) or a business development company as
defined in Section 2(a)(48) of the Investment Company Act.     [  ] 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, as
amended.     [  ] Plan established and maintained by a state, or 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.     [  ] Any employee benefit plan within the meaning of
the Employee Retirement Income Security Act of 1974, as amended, if the
investment decision is made by a plan fiduciary, as defined in the Act, which is
either a bank, savings and loan association, insurance company, or registered
investment advisor, or if the plan has assets in excess of $5,000,000 or, if a
self-directed plan, with investment decisions made solely by persons that are
Accredited Investors.     [  ] A Private Business Development Company as defined
in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended.    
[  ] An organization described in Section 501(c)(3) of the Internal Revenue
Code, a corporation or Partnership, not formed for the specific purpose of
acquiring the securities offered, with total assets in excess of $5,000,000.    
[  ]

A natural person whose individual net worth, or joint net worth with that
person’s spouse, at the time of purchase exceeds $1,000,000.

 

For purposes hereof, net worth shall be deemed to include all of your assets,
liquid or illiquid (including such items as automobile and restricted
securities), MINUS all of your liabilities, except as described below. In
calculating net worth, you must exclude the estimated fair market value of your
principal residence as an asset. Mortgage debt secured by the primary residence
shall not be included as a liability so long as such mortgage debt does not
exceed the estimated fair market value of the primary residence (except that if
the amount of such indebtedness outstanding as of the date hereof exceeds the
amount outstanding 60 days before the date hereof, other than as a result of the
acquisition of the primary residence, the amount of such excess should be
considered a liability and deducted from your net worth). However, the amount of
mortgage debt secured by the residence in excess of the value of the primary
residence should be considered a liability and deducted from your net worth.

 

 

*

As defined in Rule 501(a) of Regulation D of the Securities Act.

 

 

 

 

[  ]

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.

 

For purposes hereof the term “income” is not limited to “adjusted gross income”
as that term is defined for federal income tax purposes, but rather includes
certain items of income which are deducted in computing “adjusted gross income.”
For investors who are salaried employees, the gross salary of such investor,
minus any significant expenses personally incurred by such investor in
connection with earning the salary, plus any income from any other source
including unearned income, is a fair measure of “income” for purposes hereof.
For investors who are self-employed, “income” is generally construed to mean
total revenues received during the calendar year minus significant expenses
incurred in connection with earning such revenues.

    [  ] A trust, with assets in excess of $5,000,000, not formed for the
specific purpose of acquiring the Securities, whose purchase is directed by a
sophisticated person as described in Rule 506(b)(2) (ii) of Regulation D of the
Act.     [  ] Any entity in which all of the equity owners are Accredited
Investors.     [  ] A director or officer of the Company.

 

 

 

 

SIGNATURE PAGE

 

I/We am(are) affirming that all the information contained herein is true and
correct to the best of my/our knowledge and belief, including the attached
schedule. If I am signing on behalf of an entity or trust I represent I have the
authority to make investment decisions for the entity. I also understand that a
background/credit check maybe conducted for the purposes of detecting and
deterring money laundering.

 

      Signature   Date             Print Name                 Title (if
applicable)                 Signature   Date             Print Name            
    Title (if applicable)    

 

The foregoing subscription is accepted and the Company hereby agrees to be bound
by its terms.

 

LONG BLOCKCHAIN CORP.

 

      Name   Title:             Date