NON BROKERED PRIVATE PLACEMENT SUBSCRIPTION

 
WESTERN STANDARD ENERGY CORP.

PRIVATE PLACEMENT

INSTRUCTIONS TO SUBSCRIBER:

1.
COMPLETE the information on page 2 of this Subscription Agreement.

2.
If resident in the United States, COMPLETE the Prospective Investor Suitability
Questionnaire attached as Appendix 1 to this Subscription Agreement (the "US
Questionnaire").

 
(collectively, the “Questionnaires”)

3.
COURIER the originally executed copy of the entire Subscription Agreement,
together with the Questionnaire, and the Subscription Proceeds to the Company
at:

Western Standard Energy Corp.
c/o Clark Wilson LLP
800-885 West Georgia Street, Vancouver, BC  V6C 3H1

 
 

WE MUST RECEIVE YOUR COMPLETED SUBSRIPTION AGREEMENT AND PAYMENT IN FULL NOT
 
LATER THAN 3 PM P.S.T. ON FEBRUARY 12, 2010 TO BE CONSIDERED FOR ACCEPTANCE.

 

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

 

PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT
 
TO:
Western Standard Energy Corp.   c/o Clark Wilson LLP 800-885 West Georgia
Street, Vancouver, BC  V6C 3H1

Subject and pursuant to the attached “Terms and Conditions” of this Subscription
Agreement, including all schedules and appendices attached hereto, the
Subscriber hereby irrevocably subscribes for, and on the Closing Date, will
purchase from the Company, the following securities at the following price:
100,000 Units
US$0.00125 per Unit for a total purchase price of ___$125.00______
The Subscriber owns, directly or indirectly, the following securities of the
Company:
Nil                                                                                                                   
[Check if applicable]  The Subscriber is  an affiliate of the Company

 
The Subscriber directs the Company to issue, register and deliver the
certificates representing the Shares as follows:
 
REGISTRATION INSTRUCTIONS
 
DELIVERY INSTRUCTIONS
     
Name to appear on certificate
 
Name and account reference, if applicable
     
Account reference if applicable
 
Contact name
     
Address
 
Address
         
Telephone Number

 
EXECUTED by the Subscriber this ______ day of _________, 2010.
 
WITNESS:
 
EXECUTION BY SUBSCRIBER:
   
X
Signature of Witness
 
Signature of individual (if Subscriber is an individual)
   
X
Name of Witness
 
Authorized signatory (if Subscriber is not an individual)
     
Address of Witness
 
Name of Subscriber (please print)
         
Name of authorized signatory (please print)
ACCEPTED this 12th day of February, 2010
   
WESTERN STANDARD ENERGY CORP.
 
Address of Subscriber (residence)
per:
   

 
Telephone Number
Authorized Signatory
       
E-mail address
         
Social Security/ Social Insurance No.:

By signing this acceptance, the Subscriber agrees to be bound by the term and
conditions of this Subscription Agreement.

 
2

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

 

NONE OF THE SECURITIES TO WHICH THIS PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT
(THE “SUBSCRIPTION AGREEMENT”) RELATES HAVE BEEN REGISTERED UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED (THE “1933 ACT”), OR ANY U.S. STATE
SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD IN THE
UNITED STATES OR, DIRECTLY OR INDIRECTLY, TO U.S. PERSONS (AS DEFINED HEREIN)
EXCEPT PURSUANT TO AN EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE
REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE
WITH APPLICABLE STATE SECURITIES LAWS.
 
TERMS AND CONDITIONS
 
1.
Subscription

 
1.1                      The undersigned (the "Subscriber") hereby irrevocably
subscribes for and agrees to purchase the number of shares of the Company's
common stock (the "Shares") as set out on page 2 of this Subscription Agreement
at a price of US$0.00125 per unit, each unit comprised of one common
share.  (such subscription and agreement to purchase being the "Subscription"),
for the total subscription price as set out on page 2 of this Subscription
Agreement (the "Subscription Proceeds"), which Subscription Proceeds are
tendered herewith, on the basis of the representations and warranties and
subject to the terms and conditions set forth herein.
 
1.2           The Company hereby agrees to sell, on the basis of the
representations and warranties and subject to the terms and conditions set forth
herein, to the Subscriber the Shares.  Subject to the terms hereof, the
Subscription Agreement will be effective upon its acceptance by the Company.
 
1.3           Unless otherwise provided, all dollar amounts referred to in this
Subscription Agreement are in lawful money of the United States of America.
 
2.
Payment

 
2.1           The Subscription Proceeds must accompany this Subscription and
shall be paid by bank draft, money order or cheque drawn on a major U.S. bank or
Canadian chartered back acceptable to the Company and paid to Clark Wilson LLP,
In Trust.  If the funds are wired to the Company's lawyers, those lawyers are
authorized to immediately deliver the funds to the Company without further
authorization from the Subscriber.
 
2.2           The Subscriber acknowledges and agrees that this Subscription
Agreement, the Subscription Proceeds and any other documents delivered in
connection herewith will be held by the Company's lawyers on behalf of the
Company.  In the event that this Subscription Agreement is not accepted by the
Company for whatever reason within 60 days of the delivery of an executed
Subscription Agreement by the Subscriber, this Subscription Agreement, the
Subscription Proceeds and any other documents delivered in connection herewith
will be returned to the Subscriber at the address of the Subscriber as set forth
in this Subscription Agreement without interest or deduction.
 
2.3           Where the Subscription Proceeds are paid to the Company, the
Company may treat the Subscription Proceeds as a non-interest bearing loan and
may use the Subscription Proceeds prior to this Subscription Agreement being
accepted by the Company.
 
3.
Questionnaires and Undertaking and Direction

 
3.1           The Subscriber must complete, sign and return to the Company the
following documents:
 
 
(a)
One (1) executed copy of this Subscription Agreement; and

 
 
(b)
the US Questionnaire in the form attached as Appendix 1 if the Subscriber is
resident in the United States.

 
(collectively, the “Questionnaires”)

 
3

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

 
 
3.2           The Subscriber shall complete, sign and return to the Company as
soon as possible, on request by the Company, any documents, questionnaires,
notices and undertakings as may be required by regulatory authorities, stock
exchanges and applicable law.
 
4.
Closing

 
4.1                      Closing of the purchase and sale of the Shares shall
occur on or before 3PM P.ST. on February 12, 2010 or on such other date as may
be determined by the Company in its sole discretion (the "Closing Date").  The
Subscriber acknowledges that Shares may be issued to other subscribers under
this offering (the "Offering") before or after the Closing Date.  The Company,
may, at its discretion, elect to close the Offering in one or more closings, in
which event the Company may agree with one or more subscribers (including the
Subscriber hereunder) to complete delivery of the Shares to such subscriber(s)
against payment therefore at any time on or prior to the Closing Date.
 
5.
Acknowledgements of Subscriber

 
5.1           The Subscriber acknowledges and agrees that:
 
 
(a)
none of the Shares have been registered under the 1933 Act, or under any state
securities or “blue sky” laws of any state of the United States, and, unless so
registered, may not be offered or sold in the United States or to U.S. Persons,
as that term is defined in Regulation S under the 1933 Act (“Regulation S”),
except pursuant to an exemption from, or in a transaction not subject to, the
registration requirements of the 1933 Act;

 
 
(b)
the Subscriber acknowledges that the Company has not undertaken, and will have
no obligation, to register any of the Shares under the 1933 Act;

 
 
(c)
the decision to execute this Subscription Agreement and purchase the Shares
agreed to be purchased hereunder has not been based upon any oral or written
representation as to fact or otherwise made by or on behalf of the Company.  If
the Company has presented a business plan to the Subscriber, the Subscriber
acknowledges that the business plan may not be achieved or be achievable;

 
 
(d)
the Subscriber and the Subscriber’s advisor(s) have had a reasonable opportunity
to ask questions of and receive answers from the Company in connection with the
sale of the Shares hereunder, and to obtain additional information, to the
extent possessed or obtainable without unreasonable effort or expense, necessary
to verify the accuracy of the information about the Company;

 
 
(e)
the books and records of the Company were available upon reasonable notice for
inspection, subject to certain confidentiality restrictions, by Subscribers
during reasonable business hours at its principal place of business and that all
documents, records and books in connection with the sale of the Shares hereunder
have been made available for inspection by the Subscriber, the Subscriber’s
attorney and/or advisor(s);

 
 
(f)
by execution of this Subscription Agreement the Subscriber has waived the need
for the Company to communicate its acceptance of the purchase of the Shares
pursuant to this Subscription Agreement;

 
 
(g)
all information which the Subscriber has provided to the Company in the
Questionnaires are correct and complete as of the date the Questionnaires are
signed, and if there should be any change in such information prior to the
Subscription being accepted by the Company, the Subscriber will immediately
provide the Company with such information;

 
 
(h)
the Company is entitled to rely on the representations and warranties and the
statements and answers of the Subscriber contained in this Subscription
Agreement and in the Questionnaires, and the Subscriber will hold harmless the
Company from any loss or damage it may suffer as a result of the Subscriber’s
failure to correctly complete this Subscription Agreement or the Questionnaires;

 
4

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

 
-  -

 
 
(i)
it will indemnify and hold harmless the Company and, where applicable, its
respective directors, officers, employees, agents, advisors and shareholders
from and against any and all loss, liability, claim, damage and expense
whatsoever (including, but not limited to, any and all fees, costs and expenses
whatsoever reasonably incurred in investigating, preparing or defending against
any claim, lawsuit, administrative proceeding or investigation whether commenced
or threatened) arising out of or based upon any representation or warranty of
the Subscriber contained herein or in any document furnished by the Subscriber
to the Company in connection herewith being untrue in any material respect or
any breach or failure by the Subscriber to comply with any covenant or agreement
made by the Subscriber to the Company in connection therewith;

 
 
(j)
the issuance and sale of the Shares to the Subscriber will not be completed if
it would be unlawful or if, in the discretion of the Company acting reasonably,
it is not in the best interests of the Company;

 
 
(k)
it has been advised to consult its own legal, tax and other advisors with
respect to the merits and risks of an investment in the Shares and with respect
to applicable resale restrictions and it is solely responsible (and the Company
is not in any way responsible) for compliance with applicable resale
restrictions;

 
 
(l)
none of the Shares are listed on any stock exchange or automated dealer
quotation system and no representation has been made to the Subscriber that any
of the Shares will become listed on any stock exchange or automated dealer
quotation system, except that certain market makers currently make a market in
the Company’s share of common stock on the over-the counter bulletin board in
the United States;

 
 
(m)
it is acquiring the Shares as principal for its own account, for investment
purposes only, and not with a view to, or for, resale, distribution or
fractionalization thereof, in whole or in part, and no other person has a direct
or indirect beneficial interest in such Shares;

 
 
(n)
the Subscriber is acquiring the Shares pursuant to an exemption from the
registration and prospectus requirements of applicable securities legislation in
all jurisdictions relevant to this Subscription, and, as a consequence, the
Subscriber will not be entitled to use most of the civil remedies available
under applicable securities legislation and the Subscriber will not receive
information that would otherwise be required to be provided to the Subscriber
pursuant to applicable securities legislation;

 
 
(o)
the Subscriber has been advised that the business of the Company is in a
start-up phase and acknowledges that there is no assurance that the Company will
raise sufficient funds to adequately capitalize the business or that the
business will be profitable in the future;

 
 
(p)
no documents in connection with the sale of the Shares hereunder have been
reviewed by the Securities and Exchange Commission or any state securities
administrators;

 
 
(q)
there is no government or other insurance covering any of the Shares; and

 
 
(r)
this Subscription Agreement is not enforceable by the Subscriber unless it has
been accepted by the Company.

 
6.
Representations, Warranties and Covenants of the Subscriber

 
6.1           The Subscriber hereby represents and warrants to and covenants
with the Company (which representations, warranties and covenants shall survive
the Closing) that:
 
 
(a)
the Subscriber is resident in the jurisdiction set forth on page 2 underneath
the Subscriber’s name and signature;

 
5

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

 
-  -

 
 
(b)
the Subscriber has the legal capacity and competence to enter into and execute
this Subscription Agreement and to take all actions required pursuant hereto
and, if the Subscriber is a corporation, it is duly incorporated and validly
subsisting under the laws of its jurisdiction of incorporation and all necessary
approvals by its directors, shareholders and others have been obtained to
authorize execution and performance of this Subscription Agreement on behalf of
the Subscriber;

 
 
(c)
the Subscriber (i) has adequate net worth and means of providing for its current
financial needs and possible personal contingencies, (ii) has no need for
liquidity in this investment, and (iii) is able to bear the economic risks of an
investment in the Shares for an indefinite period of time;

 
 
(d)
the Subscriber has made an independent examination and investigation of an
investment in the Shares and the Company and has depended on the advice of its
legal and financial advisors and agrees that the Company will not be responsible
in anyway whatsoever for the Subscriber’s decision to invest in the Shares and
the Company;

 
 
(e)
all information contained in the Questionnaires are complete and accurate and
may be relied upon by the Company and the Subscriber will notify the Company
immediately of any material change in any such information occurring prior to
the closing of the purchase of the Shares;

 
 
(f)
the entering into of this Subscription Agreement and the transactions
contemplated hereby do not result in the violation of any of the terms and
provisions of any law applicable to, or the constating documents of, the
Subscriber or of any agreement, written or oral, to which the Subscriber may be
a party or by which the Subscriber is or may be bound;

 
 
(g)
the Subscriber has duly executed and delivered this Subscription Agreement and
it constitutes a valid and binding agreement of the Subscriber enforceable
against the Subscriber;

 
 
(h)
it understands and agrees that none of the Shares have been registered under the
1933 Act or any state securities laws, and, unless so registered, none may be
offered or sold in the United States or, directly or indirectly, to U.S. Persons
(as defined herein) except pursuant to an exemption from, or in a transaction
not subject to, the Registration Requirements of the 1933 Act and in each case
only in accordance with state securities laws;

 
 
(i)
it is purchasing the Shares for its own account for investment purposes only and
not for the account of any other person and not for distribution, assignment or
resale to others, and no other person has a direct or indirect beneficial
interest is such Shares, and the Subscriber has not subdivided his interest in
the Shares with any other person;

 
 
(j)
it is able to fend for itself in the Subscription and has the ability to bear
the economic risks of its prospective investment and can afford the complete
loss of such investment;

 
 
(k)
if it is acquiring the Shares as a fiduciary or agent for one or more investor
accounts, it has sole investment discretion with respect to each such account
and it has full power to make the foregoing acknowledgments, representations and
agreements on behalf of such account;

 
 
(l)
it understands and agrees that the Company and others will rely upon the truth
and accuracy of the acknowledgments, representations and agreements contained in
sections 4 and 6 hereof and agrees that if any of such acknowledgments,
representations and agreements are no longer accurate or have been breached, it
shall promptly notify the Company;

 
 
(m)
the Subscriber is not acquiring the Shares as a result of any form of general
solicitation or general advertising including advertisements, articles, notices
or other communications published in any newspaper, magazine or similar media or
broadcast over radio, or television, or any seminar or meeting whose attendees
have been invited by general solicitation or general advertising;

 
 
(n)
no person has made to the Subscriber any written or oral representations:

 
6

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

 

 
 
(i)
that any person will resell or repurchase any of the Shares, except as noted in
Section 7, below;

 
 
(ii)
that any person will refund the purchase price of any of the Shares;

 
 
(iii)
as to the future price or value of any of the Shares; or

 
 
(iv)
that any of the Shares will be listed and posted for trading on any stock
exchange or automated dealer quotation system or that application has been made
to list and post any of the Shares of the Company on any stock exchange or
automated dealer quotation system.

 
6.2           In this Subscription Agreement, the term “U.S. Person” shall have
the meaning ascribed thereto in Regulation S and for the purpose of the
Subscription includes any person in the United States.
 
7.
Acknowledgement and Waiver

 
7.1           The Subscriber has acknowledged that the decision to purchase the
Shares was solely made on the basis of publicly available information.  The
Subscriber hereby waives, to the fullest extent permitted by law, any rights of
withdrawal, rescission or compensation for damages to which the Subscriber might
be entitled in connection with the distribution of any of the Shares.
 
8.
Representations and Warranties will be Relied Upon by the Company

 
8.1           The Subscriber acknowledges that the representations and
warranties contained herein are made by it with the intention that they may be
relied upon by the Company and its legal counsel in determining the Subscriber’s
eligibility to purchase the Shares under applicable securities legislation, or
(if applicable) the eligibility of others on whose behalf it is contracting
hereunder to purchase the Shares under applicable securities legislation.  The
Subscriber further agrees that by accepting delivery of the certificates
representing the Shares on the Closing Date, it will be representing and
warranting that the representations and warranties contained herein are true and
correct as at the Closing Date with the same force and effect as if they had
been made by the Subscriber at the Closing Date and that they will survive the
purchase by the Subscriber of the Shares and will continue in full force and
effect notwithstanding any subsequent disposition by the Subscriber of such
Shares.
 
9.
Resale Restrictions

 
9.1           The Subscriber acknowledges that any resale of the Shares will be
subject to resale restrictions contained in the securities legislation
applicable to each Subscriber or proposed transferee as set forth in paragraph 6
of this Subscription Agreement.  The Shares may not be offered or sold in the
United States unless registered in accordance with federal securities laws and
all applicable state securities laws or exemptions from such registration
requirements are available.
 
10.
Legending and Registration of Subject Securities

 
10.1                      The Subscriber hereby acknowledges that that upon the
issuance thereof, and until such time as the same is no longer required under
the applicable securities laws and regulations, the certificates representing
any of the Shares will bear a legend in substantially the following form:
 
“NONE OF THE SECURITIES TO WHICH THIS PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT
(THE “SUBSCRIPTION AGREEMENT”) RELATES HAVE BEEN REGISTERED UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED (THE “1933 ACT”), OR ANY U.S. STATE
SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD IN THE
UNITED STATES OR, DIRECTLY OR INDIRECTLY, TO U.S. PERSONS (AS DEFINED HEREIN)
EXCEPT PURSUANT TO AN EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE
REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE
WITH APPLICABLE STATE SECURITIES LAWS.”

 
7

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

 
 
 
10.2           The Subscriber hereby acknowledges and agrees to the Company
making a notation on its records or giving instructions to the registrar and
transfer agent of the Company in order to implement the restrictions on transfer
set forth and described in this Subscription Agreement.
 
11.
Costs

 
11.1           The Subscriber acknowledges and agrees that all costs and
expenses incurred by the Subscriber (including any fees and disbursements of any
special counsel retained by the Subscriber) relating to the purchase of the
Shares shall be borne by the Subscriber.
 
12.
Governing Law

 
12.1           This Subscription Agreement is governed by the laws of the State
of Nevada and the federal laws of the Canada applicable herein.  The Subscriber,
in its personal or corporate capacity and, if applicable, on behalf of each
beneficial purchaser for whom it is acting, irrevocably attorns to the
jurisdiction of the State of Nevada
 
13.
Survival

 
13.1           This Subscription Agreement, including without limitation the
representations, warranties and covenants contained herein, shall survive and
continue in full force and effect and be binding upon the parties hereto
notwithstanding the completion of the purchase of the Shares by the Subscriber
pursuant hereto.
 
14.
Assignment

 
14.1           This Subscription Agreement is not transferable or assignable.
 
15.
Execution

 
15.1           The Company shall be entitled to rely on delivery by facsimile
machine of an executed copy of this Subscription Agreement and acceptance by the
Company of such facsimile copy shall be equally effective to create a valid and
binding agreement between the Subscriber and the Company in accordance with the
terms hereof.
 
16.
Severability

 
16.1           The invalidity or unenforceability of any particular provision of
this Subscription Agreement shall not affect or limit the validity or
enforceability of the remaining provisions of this Subscription Agreement.
 
17.
Entire Agreement

 
17.1           Except as expressly provided in this Subscription Agreement and
in the agreements, instruments and other documents contemplated or provided for
herein, this Subscription Agreement contains the entire agreement between the
parties with respect to the sale of the Shares and there are no other terms,
conditions, representations or warranties, whether expressed, implied, oral or
written, by statute or common law, by the Company or by anyone else.
 
18.
Notices

 
18.1                      All notices and other communications hereunder shall
be in writing and shall be deemed to have been duly given if mailed or
transmitted by any standard form of telecommunication.  Notices to the
Subscriber shall be directed to the address on page 2 and notices to the Company
shall be directed to it at the first page of this Subscription Agreement.

 
8

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

 
 
19.                      Counterparts
 
19.1           This Subscription Agreement may be executed in any number of
counterparts, each of which, when so executed and delivered, shall constitute an
original and all of which together shall constitute one instrument.

 
9

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

 

APPENDIX 1
 
PROSPECTIVE INVESTOR SUITABILITY QUESTIONNAIRE
 
All capitalized terms herein, unless otherwise defined, have the meanings
ascribed thereto in the Subscription Agreement.
 
This Questionnaire is for use by each Subscriber who is a US person (as that
term is defined Regulation S of the United States Securities Act of 1933 (the
“1933 Act”)) and has indicated an interest in purchasing Shares of Western
Standard Energy Corp. (the “Company”).  The purpose of this Questionnaire is to
assure the Company that each Subscriber will meet the standards imposed by the
1933 Act and the appropriate exemptions of applicable state securities
laws.  The Company will rely on the information contained in this Questionnaire
for the purposes of such determination.  The Shares will not be registered under
the 1933 Act in reliance upon the exemption from registration afforded by
Section 3(b) and/or Section 4(6) of the 1933 Act.  This Questionnaire is not an
offer of Shares or any other securities of the Company in any state other than
those specifically authorized by the Company.
 
All information contained in this Questionnaire will be treated as
confidential.  However, by signing and returning this Questionnaire, each
Subscriber agrees that, if necessary, this Questionnaire may be presented to
such parties as the Company deems appropriate to establish the availability,
under the 1933 Act or applicable state securities law, of exemption from
registration in connection with the sale of the Shares hereunder.
 
The Subscriber covenants, represents and warrants to the Company that it
satisfies one or more of the categories of “Accredited Investors”, as defined by
Regulation D promulgated under the 1933 Act, as indicated below:  (Please
initial in the space provide those categories, if any, of an “Accredited
Investor” which the Subscriber satisfies)
 
 
  Category 1
An organization described in Section 501(c)(3) of the United States Internal
Revenue Code, a corporation, a Massachusetts or similar business trust or
partnership, not formed for the specific purpose of acquiring the Shares, with
total assets in excess of US $5,000,000;

 
 
  Category 2
A natural person whose individual net worth, or joint net worth with that
person’s spouse, on the date of purchase exceeds US $1,000,000;

 
 
  Category 3
A natural person who had an individual income in excess of US $200,000 in each
of the two most recent years or joint income with that person’s spouse in excess
of US $300,000 in each of those years and has a reasonable expectation of
reaching the same income level in the current year;

 
 
  Category 4
A “bank” as defined under Section (3)(a)(2) of the 1933 Act or savings and loan
association or other institution as defined in Section 3(a)(5)(A) of the 1933
Act acting in its individual or fiduciary capacity; a broker dealer registered
pursuant to Section 15 of the Securities Exchange Act of 1934 (United States);
an insurance company as defined in Section 2(13) of the 1933 Act; an investment
company registered under the Investment Company Act of 1940 (United States) or a
business development company as defined in Section 2(a)(48) of such Act; a Small
Business Investment Company licensed by the U.S. Small Business Administration
under Section 301(c) or (d) of the Small Business Investment Act of 1958 (United
States); a plan with total assets in excess of $5,000,000 established and
maintained by a state, a political subdivision thereof, or an agency or
instrumentality of a state or a political subdivision thereof, for the benefit
of its employees; an employee benefit plan within the meaning of the Employee
Retirement Income Security Act of 1974 (United States) whose investment
decisions are made by a plan fiduciary, as defined in Section 3(21) of such Act,
which is either a bank, savings and loan association, insurance company or
registered investment adviser, or if the employee benefit plan has total assets
in excess of $5,000,000, or, if a self-directed plan, whose investment decisions
are made solely by persons that are accredited investors;

 
 
  Category 5
A private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940 (United States);

 
 
  Category 6
A director or executive officer of the Company;

 
 
  Category 7
A trust with total assets in excess of $5,000,000, not formed for the specific
purpose of acquiring the Shares, whose purchase is directed by a sophisticated
person as described in Rule 506(b)(2)(ii) under the 1933 Act;

 
 
  Category 8
An entity in which all of the equity owners satisfy the requirements of one or
more of the foregoing categories;

 
Note that prospective Subscribers claiming to satisfy one of the above
categories of Accredited Investor may be required to supply the Company with a
balance sheet, prior years’ federal income tax returns or other appropriate
documentation to verify and substantiate the Subscriber’s status as an
Accredited Investor.
 
If the Subscriber is an entity which initialled Category 8 in reliance upon the
Accredited Investor categories above, state the name, address, total personal
income from all sources for the previous calendar year, and the net worth
(exclusive of home, home furnishings and personal automobiles) for each equity
owner of the said entity:
 
                                                                                                                                                   
 
                                                                                                                                                   
 
The Subscriber hereby certifies that the information contained in this
Questionnaire is complete and accurate and the Subscriber will notify the
Company promptly of any change in any such information.  If this Questionnaire
is being completed on behalf of a corporation, partnership, trust or estate, the
person executing on behalf of the Subscriber represents that it has the
authority to execute and deliver this Questionnaire on behalf of such entity.
 
IN WITNESS WHEREOF, the undersigned has executed this Questionnaire as of the
_______ day of February, 2010.
If a Corporation, Partnership or Other Entity:
 
If an Individual:
 
Print of Type Name of Entity
 
Signature of Authorized Signatory
 
Type of Entity
 
Signature
 
Print or Type Name
 
Social Security/Tax I.D. No.

 

 

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