Exhibit 10.1
 
NONE OF THE SECURITIES TO WHICH THIS SUBSCRIPTION AGREEMENT (THE “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 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.
 
STOCK OPTION AGREEMENT
(Non-Investor Relations)
 
THIS STOCK OPTION AGREEMENT made as of the __ day of June 2012.
 
BETWEEN:
 
TITAN IRON ORE CORP., with an office at 3040 N. Campbell Ave., Suite 110,
Tucson, Arizona 85719
 
(the “Company”)
 
AND:
 
__________, residing at ________________
 

 
(the “Optionee”)
 
WHEREAS:
 
A.                      The Company’s board of directors (the “Board”) has
approved and adopted an incentive stock option plan (the “Plan”), whereby the
Board is authorized to grant Options (as defined herein) to purchase common
shares of the Company to directors, officers, employees, management company
employees and consultants of the Company;
 
B.                      The Optionee provides services to the Company as ____of
the Company (the “Services”); and
 
C.                      The Company wishes to grant the Options to the Optionee
as an incentive for the continued provision of the Services;
 
NOW THEREFORE THIS AGREEMENT WITNESSETH that in consideration of other good and
valuable consideration and the sum of One ($1.00) dollar now paid by the
Optionee to the Company (the receipt and sufficiency whereof is hereby
acknowledged), it is hereby agreed by and between the parties as follows:
 
1.
In this Agreement, the following terms shall have the following meanings:

 
 
(a)
“1933 Act” means the United States Securities Act of 1933, as amended;

 
 
 

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(b)
“Date of Grant” means the date of this Agreement;

 
 
(c)
“Exercise Payment” means the amount of money equal to the Exercise Price
multiplied by the number of Optioned Shares specified in the Notice of Exercise;

 
 
(d)
“Exercise Price” means $0.20 per Optioned Share;

 
 
(e)
“Expiry Date” means the date which is ten (10) years after the Date of Grant;

 
 
(f)
“Notice of Exercise” means a notice in writing addressed to the Company at its
address first recited (or such other address of the Company as may from time to
time be notified to the Optionee in writing), substantially in the form attached
as Exhibit “A” hereto, which notice shall specify therein the number of Optioned
Shares in respect of which the Options are being exercised;

 
 
(g)
“Options” means the irrevocable right and option to purchase, from time to time,
all, or any part of the Optioned Shares granted to the Optionee by the Company
pursuant to Section 2 of this Agreement;

 
 
(h)
“Optioned Shares” means the Shares subject to the Options;

 
 
(i)
“Questionnaires” means the National Instrument 45-106 Questionnaire attached as
Exhibit “B” to this Agreement and the U.S. Accredited Investor Questionnaire
attached as Exhibit “C” to this Agreement;

 
 
(j)
“Securities” means, collectively, the Options and the Optioned Shares;

 
 
(k)
“Shareholders” means holders of record of the Shares;

 
 
(l)
“Shares” means the common shares in the capital of the Company; and

 
 
(m)
“U.S. Person” has the meaning set out in Regulation S promulgated under the 1933
Act and for the purposes of this Agreement includes any person in the United
States.

 
2.
Upon the execution and delivery of this Agreement by the Optionee to the
Company, the Company hereby grants to the Optionee, subject to the terms and
conditions hereinafter set forth, Options to purchase a total of
__________________ (__________) Optioned Shares at the Exercise Price.

 
3.
The Options shall vest as follows

 
 
(a)
25% six (6) months from the Date of Grant;

 
 
(b)
25% nine (9) months from the Date of Grant;

 
 
(c)
25% twelve (12) months from the Date of Grant;

 
 
(d)
25% eighteen (18) months from the Date of Grant;

 
4.
The Options shall, at 5:00 p.m. (Tucson Time) on the Expiry Date, forthwith
expire and be of no further force or effect whatsoever.

 
 
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5.
Subject to the provisions hereof, the Options shall be exercisable in whole or
in part (at any time and from time to time as aforesaid) by the Optionee or his
personal representative giving a Notice of Exercise together with the Exercise
Payment by cash or by certified cheque, made payable to the Company.

 
6.
Upon the exercise of all or any part of the Options and upon receipt by the
Company of the Exercise Payment, the Company shall cause to be delivered to the
Optionee or his personal representative, within ten (10) days following receipt
by the Company of the Notice of Exercise, a certificate in the name of the
Optionee or his personal representative representing, in aggregate, the number
of Optioned Shares specified in the Notice of Exercise.

 
7.
Nothing in this Agreement shall obligate the Optionee to purchase any Optioned
Shares except those Optioned Shares in respect of which the Optionee shall have
exercised the Options in the manner provided in this Agreement.

 
8.
In the event the Plan does not set out the rights and obligations of the
Optionee and the Company in respect of a consolidation or subdivision of the
Shares, or an amalgamation, merger, business combination or similar event, the
terms of the Options shall be subject to adjustment as follows:

 
 
(a)
In case the Company shall (i) subdivide its outstanding Shares into a greater
number of Shares, (ii) combine its outstanding Shares into a smaller number of
shares, or (iii) issue by reclassification, recapitalization, stock dividend or
other similar event a different number or kind of securities of the Company in
exchange for its Shares, (A) the Exercise Price shall be increased or decreased,
as the case may be, to any amount which shall bear the same relation to the
Exercise Price in effect immediately prior to such action as the total number of
Shares outstanding immediately prior to such action shall bear to the total
number of Shares outstanding immediately after such action, and (B) the Options
shall automatically be adjusted so that it shall thereafter evidence the right
to purchase the kind and number of Optioned Shares or other securities which the
Optionee would have owned and would have been entitled to receive after such
action if the Options had been exercised immediately prior to such action or any
record date with respect thereto.  An adjustment made pursuant to this
subparagraph (a) shall become effective immediately after the effective date in
the case of a subdivision, combination or reclassification.

 
 
(b)
In case of any consolidation or merger of the Company with or into another
corporation or the sale of all or substantially all of the assets of the Company
to another corporation, the Options thereafter shall be exercisable for the kind
and amount of shares of stock or other securities or property to which a holder
of the number of Shares of the Company deliverable upon exercise of the Options
would have been entitled upon such consolidation, merger or sale; and, in such
case, appropriate adjustment (as determined in good faith by the Company’s Board
of Directors) shall be made in the application of the provisions in this
Section 8, to the end that the provisions set forth in this Section 8 (including
provisions with respect to changes in and adjustments of the Exercise Price)
shall thereafter be applicable, as nearly as reasonably may be, in relation to
any shares of stock or other securities or property thereafter deliverable upon
the exercise of the Options.

 
9.
The Optionee shall have no rights whatsoever as a Shareholder in respect of any
of the Optioned Shares (including any right to receive dividends or other
distribution therefrom or thereon) except in respect of which the Option has
been properly exercised in accordance with Section 5 hereof.

 
 
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10.
The Company agrees that prior to the earlier of the expiration of the Options
and the exercise and purchase of the total number of Shares represented by the
Options, there shall be reserved for issuance and delivery upon exercise of the
Options such number of the Company’s authorized and unissued Shares as shall be
necessary to satisfy the terms and conditions of this Agreement.

 
11.
The Optionee acknowledges, represents and warrants to the Company that:

 
 
(a)
no securities commission or similar regulatory authority has reviewed or passed
on the merits of the Securities;

 
 
(b)
there is no government or other insurance covering the Securities;

 
 
(c)
the Optionee has been independently advised as to the applicable hold period
imposed in respect of the Securities by securities legislation in the
jurisdiction in which the Optionee resides and confirms that no representation
has been made respecting the applicable hold periods for the Securities and
acknowledges that the hold period indicated in this Agreement does not
constitute such representation and is aware of the risks and other
characteristics of the Securities and of the fact that the Optionee may not be
able to resell the Securities except in accordance with the applicable
securities legislation and regulatory policies;

 
 
(d)
the Company has advised the Optionee that the Company is relying on an exemption
from the requirements to provide the Optionee with a prospectus and to sell the
Securities through a person registered to sell securities under applicable
securities legislation and, as a consequence of acquiring the Securities
pursuant to this exemption, certain protections, rights and remedies provided by
applicable securities legislation, including, in most circumstances, statutory
rights of rescission or damages, will not be available to the Optionee;

 
 
(e)
the Optionee is a U.S. Person;

 
 
(f)
the Securities have not been registered under the 1933 Act or under any state
securities or “blue sky” laws of any state of the United States, and are being
offered only in a transaction not involving any public offering within the
meaning of the 1933 Act, and, unless so registered, may not be offered or sold
in the United States or to U.S. Persons, except pursuant to an effective
registration statement under the 1933 Act, or 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;

 
 
(g)
the Company will refuse to register any transfer of the Securities not made in
accordance with the provisions of Regulation S, pursuant to an effective
registration statement under the 1933 Act or pursuant to an available exemption
from, or in a transaction not subject to, the registration requirements of the
1933 Act;

 
 
(h)
the Optionee has received and carefully read this Agreement;

 
 
(i)
all information contained in this Agreement is complete and accurate and may be
relied upon by the Company;

 
 
(j)
the Optionee understands and agrees that the Company and others will rely upon
the truth and accuracy of the acknowledgements, representations, warranties,
covenants and agreements contained in this Agreement and agrees that if any of
such acknowledgements, representations and agreements are no longer accurate or
have been breached, the Optionee shall promptly notify the Company;

 
 
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(k)
the Optionee is purchasing the Securities 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 Securities, and the Optionee has not
subdivided his interest in the Securities with any other person;

 
 
(l)
the Optionee is not an underwriter of, or dealer in, the shares of the Shares,
nor is the Optionee participating, pursuant to a contractual agreement or
otherwise, in the distribution of the Securities;

 
 
(m)
the Optionee is not aware of any advertisement of any of the Securities and is
not acquiring the Securities 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 Optionee any written or oral representations:

 
 
(i)
that any person will resell or repurchase any of the Securities,

 
 
(ii)
that any person will refund the purchase price of any of the Securities, or

 
 
(iii)
as to the future price or value of any of the Securities.

 
12.
If the Company becomes listed for trading on a stock exchange in Canada, and if
any of the Options are exercised prior to the date which is four months and one
day from the Date of Grant, the certificates representing the Optioned Shares to
be issued pursuant to such exercise shall bear the following legend:

 
“UNLESS PERMITTED UNDER SECURITIES LEGISLATION, THE HOLDER OF THE SECURITIES
SHALL NOT TRADE THE SECURITIES BEFORE [THE DATE THAT IS FOUR MONTHS AND ONE DAY
FROM THE DATE OF GRANT].”
 
13.
If the Company becomes listed for trading on a stock exchange in Canada, and if
any of the Options are granted where the Exercise Price is based on the
Discounted Market Price, as such term is defined by the policies of the TSX
Venture Exchange, and if any of the Options are exercised prior to the date
which is four months and one day from the Date of Grant, the certificates
representing the Securities shall bear the following legend:

 
“WITHOUT PRIOR WRITTEN APPROVAL FROM THE EXCHANGE AND COMPLIANCE WITH ALL
APPLICABLE SECURITIES LEGISLATION, THE SECURITIES REPRESENTED BY THIS
CERTIFICATE MAY NOT BE SOLD, TRANSFERRED, HYPOTHECATED OR OTHERWISE TRADED
THROUGH THE FACILITIES OF THE TSX VENTURE EXCHANGE OR OTHERWISE IN CANADA OR TO
OR FOR THE BENEFIT OF A CANADIAN RESIDENT UNTIL [THE DATE THAT IS FOUR MONTHS
AND ONE DAY FROM THE DATE OF GRANT].”
 
 
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14.
The Optionee 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 Securities will bear a
legend in substantially the following form:

 
“NONE OF THE SECURITIES REPRESENTED HEREBY 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 EXCEPT
PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE 1933 ACT OR 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.”
 
15.
The Optionee 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 Agreement.

 
16.
Unless the Company permits otherwise, the Optionee shall pay the Company in cash
all local, provincial and federal withholding taxes applicable to the grant or
exercise of the Options, or the transfer or other disposition of Shares acquired
upon exercise of the Options.  Any such payment must be made promptly when the
amount of such obligation becomes determinable.  The Company may, in lieu of
such cash payment, withhold that number of Shares sufficient to satisfy such
withholding.

 
17.
The Company will pay all issuance taxes, if any, attributable to the initial
issuance of Shares upon the exercise of the Option; provided, however, that the
Company shall not be required to pay any tax or taxes which may be payable in
respect of any transfer involved in the issue or delivery of any certificates
for Shares in a name other than that of the Optionee.

 
18.
This Agreement shall enure to the benefit of and be binding upon the Company,
its successors and assigns, and the Optionee and his personal representative, if
applicable.

 
19.
This Agreement shall not be transferable or assignable by the Optionee or his
personal representative and the Options may be exercised only by the Optionee or
his personal representative; provided that, subject to the prior approval of the
Board and, if necessary, any applicable stock exchange, the Optionee may assign
the Options to a company of which all of the voting securities are beneficially
owned by the Optionee, which ownership will continue for as long as any portion
of the Options remain unexercised.

 
20.
The granting of the Options and the terms and conditions hereof shall be subject
to the approval of any applicable regulatory authority or stock exchange.

 
21.
The Optionee and the Company represent that the Optionee is either a director,
officer, employee, management company employee or consultant of the Company or
any subsidiary of the Company (a “Subsidiary”), or a company of which all of the
voting securities are beneficially owned by one or more of the foregoing.

 
22.
The Optionee represents that he has not been induced to enter into this
Agreement by the expectation of employment or continued employment or retention
or continued retention by the Company or any Subsidiary.

 
 
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23.
The Option will terminate under the following circumstances:

 
 
(a)
If the Optionee is an employee, management company employee, consultant,
director or officer of the Company or a Subsidiary, and ceases to be an
employee, management company employee, consultant, director or officer by reason
of termination or removal for cause, the Option will terminate on the effective
date of the Optionee ceasing to be an employee, management company employee,
consultant, director or officer, as the case may be, for that reason.

 
 
(b)
If the Optionee dies, the Optionee’s personal representative will have the right
to exercise any unexercised portion of the Option, in whole or in part, at any
time until the earlier of (i) the Expiry Date and (ii) the date that is thirty
(30) days after the date of the Optionee’s death.

 
 
(c)
If the Optionee is a director, officer, employee, management company employee or
consultant of the Company or a Subsidiary, and ceases to be a director, officer,
employee, management company employee or consultant for any reason other than as
set out in subparagraphs (a) or (b) above, the Option will terminate on the
earlier of (i) the Expiry Date and (ii) the date that is 90 days after the
effective date of the Optionee ceasing to be a director, officer, employee,
management company employee or consultant for that other reason.

 
 
(d)
If the Optionee ceases to be one type of Optionee (i.e., director, officer,
employee, management company employee, or consultant, or a company 100%
beneficially owned by one of them) but concurrently is or becomes one or more
other type of Optionee, the Option will not terminate but will continue in full
force and effect and the Optionee may exercise the Option until the earlier of
(i) the Expiry Date and (ii) the applicable date set forth in subparagraphs (a),
(b) or (c) above where the Optionee ceases to be any type of Optionee.

 
 
(e)
The Option will not be affected by any change of the Optionee’s employment where
the Optionee continues to be employed by the Company or any Subsidiary.

 
24.
Neither this Agreement nor the Plan confers on the Optionee the right to
continue in the employment of or association with the Company or any Subsidiary,
nor do they interfere in any way with the right of the Optionee or the Company
or any Subsidiary to terminate the Optionee’s employment at any time.

 
25.
Reference is made to the Plan for particulars of the rights and obligations of
the Optionee and the Company in respect of:

 
 
(a)
the terms and conditions on which the Option is granted; and

 
 
(b)
a consolidation or subdivision of the Company’s share capital or an amalgamation
or merger;

 
all to the same effect as if the provisions of the Plan were set out in this
Agreement and to all of which the Optionee assents.
 
26.
The Company will give a copy of the Plan to the Optionee on request.

 
27.
Time is of the essence of this Agreement.

 
 
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28.
The terms of the Option are subject to the provisions of the Plan, as the same
may from time to time be amended, and any inconsistencies between this Agreement
and the Plan, as the same may be from time to time amended, shall be governed by
the provisions of the Plan.

 
29.
If at any time during the term of this Agreement the parties deem it necessary
or expedient to make any alteration or addition to this Agreement, they may do
so by means of a written agreement between them which shall be supplemental
hereto and form part hereof and which shall be subject to the approval of any
applicable stock exchange.

 
30.
Wherever the plural or masculine are used throughout this Agreement, the same
shall be construed as meaning singular or feminine or neuter or the body politic
or corporate where the context of the parties thereto require.

 
31.
This Agreement may be executed in several parts in the same form and such parts
as so executed shall together constitute one original agreement, and such parts,
if more than one, shall be read together and construed as if all the signing
parties hereto had executed one copy of this Agreement.

 
32.
Delivery of an executed copy of this Agreement by electronic facsimile
transmission or other means of electronic communication capable of producing a
printed copy will be deemed to be execution and delivery of this Agreement as of
the date first above written.

 
33.
Unless otherwise expressly stated, all amounts set out in this Agreement are
stated in United States dollars.

 
34.
Time shall be of the essence of this Agreement.

 
35.
This Agreement shall be exclusively governed by and construed in accordance with
the laws of the State of Arizona without giving effect to any choice or conflict
of law provision or rule that would cause the application of the domestic
substantive laws of any other jurisdiction, and shall bind and inure to the
benefit of the parties hereto and their respective successors and assigns.

 
 
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IN WITNESS WHEREOF the parties have executed this Agreement as of the date set
out above.
 
TITAN IRON ORE CORP.
 
Per:
       
Authorized Signatory
   

 
SIGNED by ___________ in the presence of:
)
   
)
   
)
 
Signature
)
   
)
 
Print Name
)
   
)
 
Address
)
   
)
   
)
   
)
 
Occupation
)
   
)
 

 
 
 
 
 
 
 
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EXHIBIT A
 
TO:
TITAN IRON ORE CORP.. (the “Company”)

 
3040 N. Campbell Ave., Suite 110

 
Tuscon, Arizona 85719

 
NOTICE OF EXERCISE
 
This Notice of Exercise shall constitute proper notice pursuant to Section 5 of
that certain Stock Option Agreement (the “Agreement”) dated as of the ____ day
of _____________, 2012, between the Company and the undersigned.
 
The undersigned hereby elects to exercise Optionee’s option to purchase
__________________ shares of the common stock of the Company at a price of
$_______ per share, for aggregate consideration of $__________, on the terms and
conditions set forth in the Agreement and the Plan.  Such aggregate
consideration, in the form specified in Section 5 of the Agreement, accompanies
this notice.  The undersigned reconfirms the representations and warranties set
out in the Agreement as of the date hereof.
 
The Optionee hereby directs the Company to issue, register and deliver the
certificates representing the shares as follows:
 
Registration Information:
 
Delivery Instructions:
     
Name to appear on certificates
 
Name
     
Address
 
Address
                     
Telephone Number

 
DATED at _____________________________, the _______ day of
_____________________, _______.

         
(Name of Optionee – Please type or print)
         
(Signature and, if applicable, Office)
         
(Address of Optionee)
         
(Address of Optionee)
         
(Fax Number)

 
 
 

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EXHIBIT B
 
NATIONAL INSTRUMENT 45-106 QUESTIONNAIRE
 
REQUIRED FOR CANADIAN OPTIONEES ONLY
 
All capitalized terms herein, unless otherwise defined, have the meanings
ascribed thereto in the Option Agreement.
 
The Optionee covenants, represents and warrants to the Company that:
 
 
1.
the Optionee is (tick one or more of the following boxes):

 

                                   
(A)          
a director, executive officer or control person of the Company or an affiliate
of the Company
o
         
(B)
a spouse, parent, grandparent, brother, sister, child or grandchild of a
director, executive officer or control person of the Company or an affiliate of
the Company
o
         
(C)
a parent, grandparent, brother, sister, child or grandchild of the spouse of a
director, executive officer or control person of the Company or an affiliate of
the Company
o
         
(D)
a close personal friend of a director, executive officer, control person of the
Company or affiliate of the Company
o
         
(E)
a close business associate of a director, executive officer, control person of
the Company or affiliate of the Company
o
         
(F)
an accredited investor
o
         
(G)
a company, partnership or other entity of which a majority of the voting
securities are beneficially owned by, or a majority of the directors are,
persons described in paragraphs A to F
o
         
(H)
a trust or estate of which all of the beneficiaries or a majority of the
trustees or executors are persons described in paragraphs A to F
o

 
 
2.
if the Optionee has checked box B, C, D, E, G or H in paragraph 1 above, the
director, executive officer, founder or control person of the Company with whom
the undersigned has the relationship is:

 

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(Instructions to Optionee: fill in the name of each director, executive officer
and control person which you have the above-mentioned relationship with.  If you
have checked box G or H, also indicate which of A to F describes the
securityholders, directors, trustees or beneficiaries which qualify you as box G
or H and provide the names of those individuals.  Please attach a separate page
if necessary).
 
 
3.
if the Optionee has ticked box F in Section 1 above, the Optionee satisfies one
or more of the categories of “accredited investor” (as that term is defined in
National Instrument 45-106) indicated below (please check the appropriate box):

 
 
 

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o
(a) an individual who either alone or with a spouse beneficially owns, directly
or indirectly, financial assets (as defined in National Instrument 45-106)
having an aggregate realizable value that, before taxes but net of any related
liabilities, exceeds $1,000,000;

 
 
o
(b) an individual whose net income before taxes exceeded $200,000 in each of the
two most recent calendar years or whose net income before taxes combined with
that of a spouse exceeded $300,000 in each of those years and who, in either
case, reasonably expects to exceed that net income level in the current calendar
year;

 
 
o
(c) an individual who, either alone or with a spouse, has net assets of at least
$5,000,000; or

 
 
o
(d) a person, other than an individual or investment fund, that had net assets
of at least $5,000,000 as reflected on its most recently prepared financial
statements.

 
IN WITNESS WHEREOF, the undersigned has executed this Questionnaire as of the
________ day of __________________, 2012.

If an Individual:
 
If a Corporation, Partnership or Other Entity:
                         
Signature
 
Print or Type Name of Entity
                         
Print or Type Name
 
Signature of Authorized Signatory
                             
Type of Entity
 

 
 

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EXHIBIT C
 
U.S. ACCREDITED INVESTOR QUESTIONNAIRE
 
All capitalized terms herein, unless otherwise defined, have the meanings
ascribed thereto in the Option Agreement.
 
This US Questionnaire is for use by the Optionee in connection with a grant of
Options from Titan Iron Ore Corp. (the “Company”).  The purpose of this US
Questionnaire is to assure the Company that the Optionee will meet the standards
imposed by the Securities Act of 1933, as amended (the “1933 Act”) and the
appropriate exemptions of applicable state securities laws.  The Company will
rely on the information contained in this US Questionnaire for the purposes of
such determination.  This US Questionnaire is not an offer of securities in any
state other than those specifically authorized by the Company.
 
The Optionee covenants, represents and warrants to the Company that it satisfies
one or more of the categories of “Accredited Investor”, 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
Optionee 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 corporation as defined in Section 2(13) of the 1933 Act; an
investment corporation registered under the Investment Corporation Act of 1940
(United States) or a business development corporation as defined in
Section 2(a)(48) of such Act; a Small Business Investment Corporation 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 US$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 corporation or registered investment adviser, or if the
employee benefit plan has total assets in excess of US$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 corporation as defined in Section 202(a)(22) of
the Investment Advisers Act of 1940 (United States).

 
 
 

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  Category 6         
A director or executive officer of the Company.
     
                 
  Category 7
A trust with total assets in excess of US$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 the Optionee 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 Optionee’s status as an Accredited Investor.
 
If the Optionee 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:
 

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The Optionee hereby certifies that the information contained in this US
Questionnaire is complete and accurate and the Optionee will notify the Company
promptly of any change in any such information.  If this US Questionnaire is
being completed on behalf of a corporation, partnership, trust or estate, the
person executing on behalf of the Optionee represents that it has the authority
to execute and deliver this US Questionnaire on behalf of such entity.
 
IN WITNESS WHEREOF, the undersigned has executed this US Questionnaire as of the
___ day of _______________, 2012.

If a Corporation, Partnership or Other Entity:
 
If an Individual:
                 
Print of Type Name of Entity
 
Signature
           
Signature of Authorized Signatory
 
Print or Type Name
           
Type of Entity
 
Social Security/Tax I.D. No. (if applicable)

 
 

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