EXHIBIT 10.1

GlenRose Instruments Inc.

4% Convertible Debentures Due 2013
Subscription Agreement

Dear Sir or Madam:

1. Subscription. The undersigned, intending to be legally bound, irrevocably
subscribes for and agrees to purchase the aggregate U.S. dollar amount of the 4%
Convertible Debentures Due 2013 (each a “Debenture” and collectively, the
“Debentures”), of GlenRose Instruments Inc., a Delaware corporation (the
“Company”), indicated on the signature page hereof, on the terms and conditions
described herein and in the Debenture.

The undersigned herewith delivers to the Company the consideration (“Purchase
Price”) required to purchase the Debenture subscribed for hereunder by wire
transfer funds payable to: GlenRose Instruments Inc., 45 First Avenue, Waltham,
MA 02451. The minimum subscription is for $500,000 unless otherwise determined
in the discretion of the Company. Capitalized terms not otherwise defined in
this Agreement have the meanings specified in the Debenture.

2. Company Representations, Warranties and Covenants. Except as disclosed
pursuant to the Company’s publicly available reports filed with the Securities
and Exchange Commission (the “SEC”) pursuant to Sections 12, 13 and 15(d)of the
Securities Exchange Act of 1934, as amended (the “Exchange Act”), the Company
represents and warrants to the undersigned as follows as of the date hereof:
 
2.01 Organization and Standing of the Company. The Company is a duly organized
and validly existing corporation in good standing under the laws of the
jurisdiction in which it was organized and has all requisite corporate power and
authority for the ownership and operation of its properties and for the carrying
on of its business as now conducted and as now proposed to be conducted. The
Company is duly licensed or qualified and in good standing as a foreign
corporation authorized to do business in all jurisdictions wherein the character
of the property owned or leased, or the nature of the activities conducted, by
it makes such licensing or qualification necessary except where the failure to
have such licenses, qualifications or authority would not have a material
adverse effect on the business of the Company ("Company Adverse Effect").

2.02 Corporate Action and Valid Issuance. The Company has all necessary
corporate power and authority to execute, deliver and perform its obligations
under this Agreement, the Investor Rights Agreement executed as of the date
hereof, the Debenture and any other agreements and instruments executed in
connection herewith (collectively, the “Transaction Agreements”). All corporate
action on the part of the Company, its officers, directors and stockholders
necessary for the authorization of the Debentures, the authorization, execution,
delivery and performance of the Transaction Agreements and the consummation of
the transactions contemplated therein has been taken. The execution, delivery
and performance of the Transaction Agreements by the Company, the issuance of
the Common Stock (the “Conversion Shares”) upon conversion of the Debentures in
accordance with their terms and the consummation of the other transactions
contemplated herein do not require any approval of the Company’s stockholders
(other than such approval as has been obtained). The Transaction Agreements have
been duly executed and delivered by the Company and constitute, and all the
covenants therein contained constitute the valid and legally binding obligations
of the Company, enforceable in accordance with their terms, subject only to the
effect of bankruptcy, insolvency, moratorium, and similar laws affecting the
rights of creditors generally. Neither the issuance of the Debentures, nor the
issuance of shares of Common Stock upon the conversion of the Debentures, is
subject to preemptive or other similar statutory or contractual rights and will
not conflict with any provisions of any agreement or instrument to which the
Company is a party or by which it is bound, including without limitation, the
articles of incorporation and bylaws of the Company.

 
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2.03 Securities Act. The Company has complied and will comply with all
applicable federal and state securities laws in connection with the issuance of
the Debentures and any Conversion Shares. Neither the Company nor anyone acting
on its behalf has offered or will offer to sell the Debentures, or solicit
offers with respect thereto from, or enter into any preliminary conversations or
negotiations relating thereto with, any person, so as to bring the issuance and
sale of the Debentures or the issuance of the Conversion Shares under the
registration provisions of the Securities Act or any state securities laws.

2.04 Employee Matters. Except as would not reasonably likely to result in a
Company Adverse Effect, each benefit plan of the Company has been established
and administered in accordance with its terms and in compliance with the
applicable provisions of Employee Retirement Income Security Act of 1974, as
amended, the Internal Revenue Code of 1986, as amended, and other applicable
laws, rules and regulations. The Company and its subsidiaries are in compliance
with all federal, state, local and foreign requirements regarding employment.

2.05 Capitalization; Status of Capital Stock

(a) On the date of this Agreement and immediately prior to the issuance of
Debentures contemplated by this Agreement, the Company has a total authorized
capitalization consisting of: (i) 10,000,000 shares of Common Stock of which
3,117,647 are issued and outstanding and (ii) 3,000,000 shares of Preferred
Stock, of which none are issued and outstanding. As of the date of this
Agreement and immediately prior to the issuance of Debentures contemplated by
this Agreement, 700,000 shares of Common Stock have been reserved for issuance
in accordance with the Company’s 2005 Stock Option and Incentive Plan. Of those
shares the Company granted: (i) nonqualified options to purchase 230,000 shares
of the Company’s Common Stock that are currently not exercised and (ii) 15,000
shares of restricted common stock.

(b) Schedule 2.05 sets forth the capitalization of the Company immediately
following the issuance of the Debentures contemplated by this Agreement
including the number of shares of the following: (i) issued and outstanding
Common Stock; (ii) Common Stock reserved for issuance upon conversion of
Debenture, including the names of the holders of the Debentures thereof; (iii)
issued stock options, including vesting schedule and exercise price; (iv) stock
options not yet issued but reserved for issuance; (v) issued and outstanding
Preferred Stock; and (vi) warrants or stock purchase rights, if any. All of the
outstanding shares of capital stock of the Company have been duly authorized,
are validly issued and are fully paid and nonassessable and were issued in
compliance with all applicable federal and state securities laws. The Debentures
have been duly authorized, and when issued, sold and delivered in accordance
with the terms and for the consideration set forth in this Agreement, will be
validly issued. The Company has duly reserved the Conversion Shares for issuance
upon conversion of the Debentures, and the Conversion Shares, when issued and
delivered upon conversion of the Debentures, will be duly authorized, validly
issued and fully paid and non assessable. Except as set forth on Schedule 2.05,
there are no options, warrants or rights to purchase shares of capital stock or
other securities of the Company authorized, issued or outstanding, nor is the
Company obligated in any other manner to issue shares of its capital stock or
other securities. There are no restrictions on the transfer of shares of capital
stock of the Company other than those imposed by the Transaction Agreements and
state and federal securities laws. No holder of any security of the Company is
entitled to preemptive or similar statutory or contractual rights, either
arising pursuant to any agreement or instrument to which the Company is a party,
or which are otherwise binding upon the Company, which have not been waived. The
offer and sale of all shares of capital stock and other securities of the
Company issued before the date hereof complied with or were exempt from all
federal and state securities laws.

 
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2.06 Government Consents and Filings. Assuming the accuracy of the
representations made by the undersigned in Section 2 of this Agreement, no
consent, approval, order or authorization of, or registration, qualification,
designation, declaration or filing with, any federal, state or local
governmental authority is required on the part of the Company in connection with
the consummation of the transactions contemplated by this Agreement.
 
2.07 Litigation. There is no claim, action, suit, proceeding, arbitration,
complaint, charge or investigation pending or, to the Company’s knowledge,
currently threatened against the Company which individually or in the aggregate
would reasonably be expected to have a Company Adverse Effect, nor are there any
orders, writs, injunctions, judgments or decrees outstanding of any court or
governmental agency or instrumentality and binding upon the Company that would
reasonably be expected to have a Company Adverse Effect. To the Company’s
knowledge, the Company is not currently subject to any investigation by any
governmental body with respect to any allegation of “backdating” options granted
to any employees or directors that would reasonably be expected to have a
Company Adverse Effect.

2.08 Intellectual Property. Except as would not reasonably be expected to have a
Company Adverse Effect: (a) the Company owns, or possesses sufficient rights to
use, all patents, patent applications, trademarks, trademark applications,
service marks, trade names, copyrights, trade secrets, licenses, domain names,
mask works, information and proprietary rights and processes as are necessary to
the conduct of the Company’s business as now conducted and as presently proposed
to be conducted (collectively, “Company Intellectual Property”) necessary for
the conduct of its business as currently conducted; (b) to the Company’s
knowledge, the use by the Company of any Company Intellectual Property used in
the conduct of the Company’s business as currently conducted does not infringe
on or otherwise violate the rights of any person; (c) the use of any licensed
Company Intellectual Property by the Company is in accordance with applicable
licenses pursuant to which the Company acquired the right to use such Company
Intellectual Property and (d) to the knowledge of the Company, no person is
challenging, infringing on or otherwise violating any right of the Company with
respect to any Company Intellectual Property owned by and/or exclusively
licensed to the Company.

2.09 Compliance with Other Instruments. The Company is not in violation or
default (a) of any provisions of its articles of incorporation or bylaws, (b) of
any instrument, judgment, order, writ or decree, or (c) under any agreement to
which it is a party or by which it is bound, or of any provision of federal or
state statute, rule or regulation applicable to the Company, the violation of
which would have a Company Adverse Effect.

2.10 Absence of Liens. The property and assets that the Company owns are free
and clear of all mortgages, deeds of trust, liens, loans and encumbrances,
except for statutory liens for the payment of current taxes that are not yet
delinquent and encumbrances and liens that arise in the ordinary course of
business and do not materially impair the Company’s ownership or use of such
property or assets. With respect to the property and assets it leases, the
Company is in compliance with such leases and, to its knowledge, holds a valid
leasehold interest free of any liens, claims or encumbrances other than those of
the lessors of such property or assets.

2.11 Tax Returns and Payments. There are no federal, state, county, local or
foreign taxes dues and payable by the Company which have not been timely paid.
There are no accrued and unpaid federal, state, country, local or foreign taxes
of the Company which are due, whether or not assessed or disputed. There have
been no examinations or audits of any tax returns or reports by any applicable
federal, state, local or foreign governmental agency. The Company has duly and
timely filed all federal, state, county, local and foreign tax returns required
to have been filed by it and there are in effect no waivers of applicable
statutes of limitations with respect to taxes for any year.

 
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2.12 Permits. The Company has all franchises, permits, licenses and any similar
authority necessary for the conduct of its business, the lack of which could
reasonably be expected to have a Company Adverse Effect. The Company is not in
default in any material respect under any of such franchises, permits, licenses
or other similar authority.

2.13 No Brokers or Finders. No person other than Ladenburg Thalman & Co. Inc.
has or will have, as a result of the transactions contemplated by this
Agreement, any right, interest or valid claim against or upon the Company for
any commission, fee or other compensation as a finder or broker because of any
act or omission by the Company or any agent of the Company.

2.14 SEC Reports; Financial Statements. The Company has filed all required
registration statements, prospectuses, reports, schedules, forms, statements and
other documents required to be filed by it with the SEC (the “SEC Reports”)
since November 2006. The information contained or incorporated by reference in
the SEC Reports was true and correct in all material respects as of the
respective dates of the filing thereof with the SEC (or if amended or superseded
by a filing prior to the date of this Agreement, then on the date of such
filing); and, as of such respective dates, the SEC Reports did not contain an
untrue statement of a material fact or omit to state a material fact required to
be stated therein or necessary to make the statements therein, in light of the
circumstances under which they were made, not misleading. All of the SEC
Reports, as of their respective dates, complied as to form in all material
respects with the applicable requirements of the Securities Act and the Exchange
Act and the rules and regulations promulgated thereunder. The financial
statements of the Company included in the SEC Reports (collectively, the
“Financial Statements”) fairly present in all material respects the consolidated
financial position of the Company and its Subsidiaries as of the dates
indicated, and the results of its operations and cash flows for the periods
therein specified, all in accordance with United States generally accepted
accounting principles applied on a consistent basis (“GAAP”) throughout the
periods therein specified (except as otherwise noted therein, and in the case of
quarterly financial statements except for the absence of footnote disclosure and
subject, in the case of interim periods, to normal year-end adjustments). Except
as disclosed in the SEC Reports, the Company and its Subsidiaries have not
incurred any liabilities that are of a nature that would be required to be
disclosed on a balance sheet of the Company and its Subsidiaries or the
footnotes thereto prepared in conformity with GAAP, other than (i) liabilities
incurred in the ordinary course of business since October 1, 2006, and (ii)
liabilities that would not reasonably be expected to have a Company Material
Adverse Effect.

2.15 Absence of Changes. Since March 30, 2008, there have not been any changes,
circumstances, conditions or events which individually or in the aggregate have
had or would reasonably be expected to have a Company Material Adverse Effect.

2.16. Officers’ Conversion of Debt. Immediately prior to the execution of this
Agreement, all officers, directors, managers and affiliates of the Company who
had outstanding loans to the Company converted all such loans into the same
Debentures and each such persons has executed an Investors Rights Agreement with
the same “lockup” provision to which the undersigned has agreed.

3. Investor Representations, Warranties and Covenants. The undersigned hereby
acknowledges, represents and warrants to, and agrees with the Company as follows
as of the date hereof:

(a) The undersigned is acquiring the Debenture for the undersigned’s own account
as principal, for investment purposes only, and not with a view to, or for,
resale or distribution of all or any part of the Debenture or any shares of the
Company’s Common Stock, par value $0.01 per share, issued upon conversion of the
Debenture (the “Underlying Shares”)(the “Debenture and the Underlying Shares are
collectively referred to herein as the “Securities”), and no other person has a
direct or indirect beneficial interest in the Securities;

 
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(b) The undersigned acknowledges its understanding that the offering and sale of
the Debentures is intended to be exempt from registration under the Securities
Act of 1933, as amended (the “Securities Act”), by virtue of Sections 4(2) of
the Securities Act and Rule 505 of Regulation D (“Regulation D”) promulgated
thereunder and Section 4(6) of the Securities Act, and, in furtherance thereof,
the undersigned represents and warrants to and agrees with the Company that the
undersigned has the financial ability to bear the economic risk of the
undersigned’s investment, has adequate means for providing for the undersigned’s
current needs and contingencies and has no need for liquidity with respect to
the undersigned’s investment in the Debenture.

(c) The undersigned is an “accredited investor” as defined in Rule 501(a) of
Regulation D under the Securities Act;

(d) The undersigned:

(1) The undersigned understands and has evaluated the risks of a purchase of the
Debenture;

(2) has been given the opportunity to ask questions of and receive answers from
the Company concerning the terms and conditions of the offering of the
Debentures, and has been given the opportunity to obtain such information as the
undersigned has deemed necessary regarding the Company, the Debenture or the
Underlying Shares to the extent that the Company possesses such information or
can acquire it without unreasonable effort;

(3) has not relied on any oral representation, warranty or information in
connection with the offering of the Debentures by the Company, or any officer,
employee, agent or affiliate of the Company;

(4) has determined that the Debenture is a suitable investment for the
undersigned and that at this time the undersigned can bear a complete loss of
the undersigned’s investment therein;

(5) has such knowledge and experience in financial and business matters that the
undersigned is capable of evaluating the merits and risks of the undersigned’s
investment in the Debenture;

(e)If the undersigned is a corporation, limited liability company, partnership,
trust, qualified plan or other entity, it is authorized and qualified to become
a holder of the Securities, and the person signing this Subscription Agreement
on behalf of such entity has been duly authorized to do so;

(f) Any information which the undersigned has heretofore furnished and herewith
furnishes to the Company with respect to the undersigned’s financial position
and business experience is correct and complete as of the date of this Agreement
and if there should be any material change in such information prior to issuance
to the undersigned of the Debenture, the undersigned will immediately furnish
such revised or corrected information to the Company;

 
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(g) The foregoing acknowledgments, representations, warranties and agreements
shall survive the closing at which the Debenture is issued;

(h) The undersigned acknowledges that the undersigned has not purchased the
Debenture as a result of any general solicitation or general advertising; and

(i) The undersigned’s overall commitment to investments which are not readily
marketable is not disproportionate to the undersigned’s net worth, and the
undersigned’s investment in the Debenture and will not cause such overall
commitment to become excessive.

4. Investor Awareness. The undersigned acknowledges that:

(a) No federal or state agency has passed upon the Securities or made any
finding or determination as to the fairness of this investment;

(b) There is no established market for the Securities of and no assurance has
been given that any public market for them will develop;

(c) The Securities may not be sold, pledged or otherwise transferred, except as
may be permitted under the Securities Act and applicable state securities laws
pursuant to registration or exemption therefrom; and accordingly, the
undersigned may be required to bear the financial risks of an investment in the
Securities for an indefinite period of time;

(d) The undersigned consents to (i) the placing of a legend substantially in the
form set forth below on the certificates representing the Underlying Shares
stating that the Underlying Shares have not been registered and setting forth
the restriction on transfer contemplated hereby, and (ii) the placing of a stop
transfer order on the books of the Company with respect to the Securities.

“The shares represented by this certificate have not been registered under the
Securities Act of 1933, as amended. These shares have been acquired for
investment and not with a view to distribution or resale and may not be sold,
mortgaged, pledged, hypothecated or otherwise transferred without an effective
registration statement for such sales under the Securities Act of 1933, or an
opinion of counsel for the corporation that registration is not required under
such Act.

The shares represented by this certificate are also subject to the provisions of
a certain Investor Rights Agreement dated ___________, 2008 and may not be
transferred except in accordance with the provisions of that agreement.”
 
5. Miscellaneous.

(a) Indemnity by Investor. The investor agrees to indemnify and hold harmless
the Company, its affiliates, directors, officers, employees, agents and
controlling persons (the Company and each such person being a “Company
Indemnified Party”), from and against any and all losses, claims, damages,
liabilities and expenses whatsoever (including, but not limited to, any and all
expenses whatsoever reasonably incurred investigating, preparing or defending
against any litigation commenced or threatened or any claim whatsoever), joint
or several, as incurred, to which such Company Indemnified Party may become
subject under any applicable United States federal or state law or the laws of
any other domestic or foreign jurisdiction, or otherwise, and related to or
arising out of or based upon any false representation, warranty or
acknowledgment, or breach or failure by the undersigned to comply with any
covenant or agreement made by the undersigned herein or in any other document
furnished by the undersigned to any of the foregoing in connection with this
transaction.

 
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(b) Indemnity by the Company. The Company agrees to indemnify and hold harmless
the undersigned, its affiliates, directors, officers, employees, agents and
controlling persons (the undersigned and each such person being an “Investor
Indemnified Party”), from and against any and all losses, claims, damages,
liabilities and expenses whatsoever (including, but not limited to, any and all
expenses whatsoever reasonably incurred investigating, preparing or defending
against any litigation commenced or threatened or any claim whatsoever), joint
or several, as incurred, to which such Investor Indemnified Party may become
subject arising out of or resulting from (1) any inaccuracy or breach of the
Company’s representations and warranties in this Agreement or (2) the Company’s
breach of agreements or covenants made by the Company in this Agreement or (3)
any action, suit, proceeding or investigation by any governmental entity or any
other person relating to this Agreement or the transactions contemplated hereby.

(c) Modification. Except as otherwise provided herein, 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.

(d) 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
undersigned is more than one person, the obligation of the undersigned shall be
joint and several and the agreements, covenants, 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.

(e) Entire Agreement. This instrument contains the entire agreement of the
parties and there are no representations, warranties, acknowledgments, covenants
or other agreements except as stated or referred to herein.

(f) Assignability. This Agreement is not transferable or assignable by the
undersigned.

(g) Governing Law and Forum. Notwithstanding the place where this Agreement may
be executed by any of the parties hereto, all the terms and provisions hereof
shall be construed in accordance with and governed by the laws of the
Commonwealth of Massachusetts, without giving effect to its conflict of law
principles. Any dispute which may arise out of or in connection with this
Agreement shall be adjudicated before a court located in Middlesex County,
Massachusetts and the parties hereby submit to the exclusive jurisdiction of the
courts of the Commonwealth of Massachusetts located in Boston, Massachusetts and
of the federal courts in Boston, Massachusetts with respect to any action or
legal proceeding commenced by any party, and irrevocably waive any objection
they now or hereafter may have respecting the venue of any such action or
proceeding brought in such a court or respecting the fact that such court is an
inconvenient forum, relating to or arising out of this Agreement or any acts or
omissions relating to the sale of the Shares, and the undersigned consents to
the service of process in any such action or legal proceeding by means of
registered or certified mail, return receipt requested, in care of the address
set forth below or such other address as the undersigned shall furnish in
writing to the Company. In the event any such action is brought, whether at law
or in equity, then the prevailing party shall be paid its reasonable attorney's
fees, expenses and disbursements arising out of such action. The undersigned
hereby waives trial by jury in any action or proceeding involving, directly or
indirectly, any matter (whether sounding in tort, contract, fraud or otherwise)
in any way arising out of or in connection with this Agreement or the Holder’s
purchase of the Shares.

 
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(h) Expenses and Other Rights. The Company shall pay reasonable out-of-pocket
fees and expenses up to $15,000 incurred by the undersigned in connection with
the Transaction Agreements. The Company agrees that if it enters into an
agreement in connection with the Debentures with another investor that provides
for a material economic benefit or material right that is not provided to the
undersigned in the Transaction Agreements, the undersigned shall be
automatically entitled to such material economic benefit or right without the
execution of any amendment to the Transaction Agreements.

[The balance of this page has been intentionally left blank.]

 
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IN WITNESS WHEREOF, the undersigned has executed this Agreement on this ___ day
of _____, 2008.

Manner in which Title is to be held (Please Check One):
     
1.
___
Individual
2.
___
Joint Tenants With Right of Survivorship
3.
___
Community Property
4.
___
Tenants in Common
5.
___
Married with Separate Property

EXECUTION BY NATURAL PERSONS
 

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Exact Name(s) in Which Title is to be Held
(If Joint Tenant or Tenants in Common, both persons must
sign and this page must contain all information for both persons).
 

___________________________________
 
___________________________________
Signature
 
Signature
     
___________________________________
 
 
___________________________________
 
Name (Please Print)
 
Name (Please Print)
     
__________________________________
 
__________________________________
Residence: Number and Street
 
Residence: Number and Street
     
___________________________________
 
___________________________________
City, State, Zip Code
 
City, State, Zip Code
     
___________________________________
 
___________________________________
Social Security Number
 
Social Security Number
     
___________________________________
   
Telephone Number
         
___________________________________
   
Email
   

Accepted this ___ day of _____ 2008, on behalf of the Company

GLENROSE INSTRUMENTS INC.

By: __________________________

Name: Anthony S. Loumidis
Title: Chief Financial Officer

 
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EXECUTION BY SUBSCRIBER THAT IS AN ENTITY

(Corporation, Limited Liability Company, Partnership, Trust, Etc.)

______________________________________________
Name of Entity (Please Print)

Date of Incorporation or Organization:
_____________________________________________________
 
State of Principal Offices:
______________________________________________________________
 
Federal Taxpayer Identification Number:
___________________________________________________
 

 
By:
__________________________________
       
Title:
__________________________________
       
Address:
__________________________________
        _________________________________________        
_________________________________________        
_________________________________________   Taxpayer Identification Number

Accepted this ___ day of _____ 2008, on behalf of the Company

GLENROSE INSTRUMENTS INC.

By: ___________________________

Name: Anthony S. Loumidis
Title: Chief Financial Officer

 
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ACCREDITED INVESTOR QUESTIONNAIRE

Please check the box below that best characterizes the person or entity
subscribing for the Shares under the terms of the foregoing Subscription
Agreement.
 
 

  o
Any natural person whose individual net worth, or joint net worth with that
person’s spouse, at the time of his purchase exceeds US $1,000,000;

 

  o
Any 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;

 

  o
Any organization described in Section 501(c)(3) of the Internal Revenue Code, a
corporation, a Massachusetts or similar business trust or a partnership, in each
case, not formed for the purpose of this investment, with total assets in excess
of US $5,000,000;

 

  o
Any director, executive officer, or general partner of the issuer of the
securities being offered or sold, or any director, executive officer, or general
partner of a general partner of that issuer;

 

  o
Any trust with total assets in excess of US $5,000,000, not formed for the
specific purpose of acquiring the securities offered, whose purchase is directed
by a sophisticated person as described in Rule 506(b)(2)(ii) of the Securities
Act of 1933;

 

  o
Any entity in which all of the equity owners are accredited investors;

 

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

 

  o
Any 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;

 

  o
Any 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;

 

  o 
Any 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;

 

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

 

  o
Any employee benefit plan within the meaning of Title I of the Employee
Retirement Income Security Act of 1974 whose investment decision is made by a
fiduciary which is either a bank, savings and loan association, insurance
company, or registered investment advisor, or whose total assets exceed US
$5,000,000, or, if a self-directed plan, a plan whose investment decisions are
made solely by persons who are accredited investors;

 

  o
Any broker or dealer registered pursuant to Section 15 of the Securities
Exchange Act of 1934; or

 

  o
Any plan established and maintained by a state, its political subdivisions, or
any agency or instrumentality of a state or its political subdivisions for the
benefit of its employees, if such plan has total assets in excess of $5,000,000.

 

  o 
None of the above.

Name of Subscriber:
_____________________________
       
Social Security Number / TIN:
_____________________________
       

 
 
 
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