Exhibit 10.1

 

SECURITIES PURCHASE AGREEMENT

 

This SECURITIES PURCHASE AGREEMENT (the “Agreement”) is dated as of [●], 2019 by
and among NeuroClear Technologies, Inc., a Delaware corporation (the “Company”),
each of the purchasers identified on the signature pages hereto and such
purchasers’ respective successors and assigns (individually, a “Purchaser” and
collectively, the “Purchasers”) and, solely with respect to Section 3.03 and
Article IV, BioSig Technologies, Inc. a Delaware corporation (the “Parent”).

 

The parties hereto agree as follows:

 

Article I.     
Purchase and Sale of COMMON Stock

 

Section 1.01     Purchase and Sale of Stock. Upon the following terms and
conditions, the Company shall issue and sell at the Closing (as defined below),
and the Purchasers, severally and not jointly, agree to purchase at the Closing,
an aggregate of up to $3,600,000 of shares of the Company’s common stock, par
value $0.001 per share (the “Common Stock”), with an aggregate number of shares
of Common Stock for each Purchaser equal to that number of shares as is set
forth on each such Purchaser’s signature page hereto (collectively, the
“Shares”), at a price per share equal to $5.00 (the “Per Share Purchase Price,”
and such amounts in the aggregate, the “Purchase Price”). The Company and the
Purchasers are executing and delivering this Agreement in accordance with and in
reliance upon the exemption from securities registration afforded by Rule 506 of
Regulation D (“Regulation D”) as promulgated by the United States Securities and
Exchange Commission (the “Commission”) under the Securities Act of 1933, as
amended (the “Securities Act”).

 

Section 1.02     Closing.

 

(a)     On the closing date (the “Closing Date”), upon the terms and subject to
the conditions set forth herein, substantially concurrent with the execution and
delivery of this Agreement by the parties hereto, the Company agrees to sell at
the closing (the “Closing”), and each Purchaser, severally and not jointly,
agree to purchase at the Closing, the number of Shares set forth on each such
Purchaser’s signature page hereto for an aggregate subscription price equal to
such number of Shares multiplied by the Per Share Purchase Price (as to each
Purchaser, the “Subscription Amount”). Each Purchaser purchasing Shares on the
Closing Date shall deliver to the Company such Purchaser’s Subscription Amount
by wire transfer of immediately available funds in accordance with the Company’s
written wire instructions, and the Company shall deliver to each Purchaser its
Shares deliverable at the Closing. Upon satisfaction of the covenants and
conditions set forth in Sections 1.03 and 1.04, the Closing shall occur at the
offices of Haynes and Boone, LLP, 30 Rockefeller Plaza, 26th Floor, New York,
New York 10112 or such other location as the parties shall mutually agree.
Notwithstanding anything herein to the contrary, the Closing Date shall occur on
or before August 9, 2019; provided, however, that such date may be extended by
the Company, without notice, for up to 60-days (the “Termination Date”).

 

(b) If the Closing is not held on or before the Termination Date, the Company
shall cause all subscription documents and funds to be returned, without
interest or deduction, to each prospective Purchaser. The Company shall also
cause any subscription documents or funds received following the Closing to be
returned, without interest or deduction, to each applicable prospective
Purchaser. Notwithstanding the foregoing, the Company in its sole discretion may
elect not to sell to any Person any or all of the Shares requested to be
purchased hereunder, provided that the Company causes all corresponding
subscription documents and funds received from such Person to be promptly
returned.

 

 

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Section 1.03     Deliveries.

 

(a)     On or prior to the Closing, the Company shall deliver or cause to be
delivered to each Purchaser purchasing the shares of Common Stock on the Closing
Date each of the following:

 

(i)     this Agreement duly executed by the Company;

 

(ii)     evidence of the issuance of the Shares in “book entry” form.

 

(b)     On or prior to the Closing Date, each Purchaser purchasing Common Stock
on the Closing Date shall deliver or cause to be delivered to the Company the
following:

 

(i)     this Agreement duly executed by such Purchaser; and

 

(ii)     such Purchaser’s Subscription Amount by wire transfer to the account
specified in writing by the Company.

 

Section 1.04     Closing Conditions.

 

(a)     The obligations of the Company hereunder in connection with the Closing
are subject to the following conditions being met:

 

(i)     the accuracy in all material respects on the Closing Date of the
representations and warranties of the Purchasers contained herein (unless as of
a specific date therein in which case they shall be accurate in all material
respects as of such date);

 

(ii)     all obligations, covenants and agreements of each Purchaser required to
be performed at or prior to the Closing Date shall have been performed; and

 

(iii)     the delivery by each Purchaser of the items set forth in Section
1.03(b) of this Agreement.

 

(b)     The respective obligations of the Purchasers hereunder in connection
with the Closing are subject to the following conditions being met:

 

(i)     the accuracy in all material respects when made and on the Closing Date
of the representations and warranties of the Company contained herein (unless as
of a specific date therein in which case they shall be accurate in all material
respects as of such date);

 

(ii)     all obligations, covenants and agreements of the Company required to be
performed at or prior to the Closing Date shall have been performed;

 

(iii)     the delivery by the Company of the items set forth in Section 1.03(a)
of this Agreement.

 

Article II.     
Representations and Warranties

 

Section 2.01     Representations and Warranties of the Company. The Company
hereby represents and warrants to the Purchasers, as of the date hereof, as
follows:

 

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(a)     Organization, Good Standing and Power. The Company is a corporation duly
incorporated, validly existing and in good standing under the laws of the State
of Delaware and has the requisite corporate power to own, lease and operate its
properties and assets and to conduct its business as it is now being conducted.
The Company is duly qualified as a foreign corporation to do business and is in
good standing in every jurisdiction in which the nature of the business
conducted or property owned by it makes such qualification necessary except for
any jurisdiction(s) (alone or in the aggregate) in which the failure to be so
qualified will not have material adverse effect on the business, operations,
assets, properties, prospects or financial condition of the Company, and/or any
condition, circumstance, or situation that would prohibit or otherwise interfere
with the ability of the Company to perform any of its obligations under this
Agreement in any material respect (each, a “Material Adverse Effect”).

 

(b)     Authorization; Enforcement. The Company has the requisite corporate
power and authority to enter into and perform this Agreement and to issue and
sell the Shares in accordance with the terms hereof and otherwise carry out its
obligations hereunder. The execution, delivery and performance of this Agreement
by the Company and the consummation by it of the transactions contemplated
hereby have been duly and validly authorized by all necessary corporate action,
and no further consent or authorization of the Company or its Board of Directors
or stockholders is required. This Agreement has been duly executed and delivered
by the Company. This Agreement constitutes a valid and binding obligation of the
Company enforceable against the Company in accordance with its terms, except as
such enforceability may be limited by applicable bankruptcy, insolvency,
reorganization, moratorium, liquidation, conservatorship, receivership or
similar laws relating to, or affecting generally the enforcement of, creditor’s
rights and remedies or by other equitable principles of general application.

 

(c)     Issuance of Securities. The Shares to be issued at the Closing have been
duly authorized by all necessary corporate action and the Shares, when paid for
or issued in accordance with the terms hereof, shall be validly issued and
outstanding, fully paid and nonassessable.

 

(d)     No Conflicts. The execution, delivery and performance of this Agreement
by the Company and the consummation by the Company of the transactions
contemplated herein do not and will not (i) conflict with or violate any
provision of the Company’s Certificate of Incorporation or Bylaws, (ii) conflict
with, or constitute a default (or an event which with notice or lapse of time or
both would become a default) under, or give to others any rights of termination,
amendment, acceleration or cancellation of, any agreement, mortgage, deed of
trust, indenture, note, bond, license, lease agreement, instrument or obligation
to which the Company is a party or by which it or its properties or assets are
bound, (iii) create or impose a lien, mortgage, security interest, charge or
encumbrance of any nature on any property of the Company under any agreement or
any commitment to which the Company is a party or by which the Company is bound
or by which any of its properties or assets are bound or (iv) result in a
violation of any federal, state, local or foreign statute, rule, regulation,
order, judgment or decree (including federal and state securities laws and
regulations) applicable to the Company or by which any property or asset of the
Company are bound or affected, except, in all cases other than violations
pursuant to clause (i) above, for such conflicts, defaults, terminations,
amendments, accelerations, cancellations and violations as would not,
individually or in the aggregate, have or reasonably be expected to have a
Material Adverse Effect.

 

(e)     Private Placement Memorandum. The Company’s Confidential Private
Placement Memorandum distributed to each Purchaser in connection with the sale
of the Shares (the “PPM”), did not, as of the date of this Agreement, contain
any untrue statement of a material fact or omit to state a material fact
required to be stated therein or necessary in order to make the statements
therein, in the light of the circumstances under which they were made, not
misleading.

 

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Section 2.02     Representations and Warranties of the Purchasers. Each of the
Purchasers hereby makes the following representations and warranties to the
Company with respect solely to itself and not with respect to any other
Purchaser:

 

(a)     Organization and Standing of the Purchasers. If the Purchaser is an
entity, such Purchaser is a corporation, limited liability company or
partnership duly incorporated or organized, validly existing and in good
standing under the laws of the jurisdiction of its incorporation or
organization.

 

(b)     Authorization and Power. Each Purchaser has the requisite power and
authority to enter into and perform this Agreement and to purchase the Shares
being sold to such Purchaser hereunder. This Agreement has been duly authorized,
executed and delivered by such Purchaser and constitutes, or shall constitute
when executed and delivered, a valid and binding obligation of such Purchaser
enforceable against such Purchaser in accordance with the terms thereof, except
as such enforceability may be limited by applicable bankruptcy, insolvency,
reorganization, moratorium, liquidation, conservatorship, receivership or
similar laws relating to, or affecting generally the enforcement of, creditor’s
rights and remedies or by other equitable principles of general application.

 

(c)     Purchase for Own Account. Each Purchaser is acquiring the Shares solely
for its own account and not with a view to or for sale in connection with
distribution. Each Purchaser does not have a present intention to sell the
Shares, nor a present arrangement (whether or not legally binding) or intention
to effect any distribution of the Shares to or through any person or entity.
Each Purchaser acknowledges that it is able to bear the financial risks
associated with an investment in the Shares and that it has been given full
access to such records of the Company and to the officers of the Company and
received such information as it has deemed necessary or appropriate to conduct
its due diligence investigation and has sufficient knowledge and experience in
investing in companies similar to the Company in terms of the Company’s stage of
development so as to be able to evaluate the risks and merits of its investment
in the Company.

 

(d)     Status of Purchasers. Such Purchaser is an “accredited investor” as
defined in Rule 501 of Regulation D promulgated under the Securities Act. Such
Purchaser is not required to be registered as a broker-dealer under Section 15
of the Exchange Act and such Purchaser is not a broker-dealer.

 

(e)     Opportunities for Additional Information. Each Purchaser acknowledges
that it has received and carefully reviewed the PPM. Each Purchaser acknowledges
that such Purchaser has had the opportunity to ask questions of and receive
answers from, or obtain additional information from, the executive officers of
the Company concerning the financial and other affairs of the Company, and to
the extent deemed necessary in light of such Purchaser’s personal knowledge of
the Company’s affairs, such Purchaser has asked such questions and received
answers to the full satisfaction of such Purchaser, and such Purchaser desires
to invest in the Company. Neither such inquiries nor any other investigation
conducted by or on behalf of such Purchaser or its representatives or counsel
shall modify, amend or affect such Purchaser’s right to rely on the truth,
accuracy and completeness of the Company’s representations and warranties
contained in this Agreement.

 

(f)     No General Solicitation. Each Purchaser acknowledges that the Shares
were not offered to such Purchaser by means of any form of general or public
solicitation or general advertising, or publicly disseminated advertisements or
sales literature, including (i) any advertisement, article, notice or other
communication published in any newspaper, magazine, or similar media, or
broadcast over television or radio or (ii) any seminar or meeting to which such
Purchaser was invited by any of the foregoing means of communications.

 

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(g)     Restricted Securities. Such Purchaser understands that the Shares must
be held indefinitely unless they are registered under the Securities Act or an
exemption from registration is available.

 

(h)     General. Such Purchaser understands that the Shares are being offered
and sold in reliance on a transactional exemption from the registration
requirement of federal and state securities laws and the Company is relying upon
the truth and accuracy of the representations, warranties, agreements,
acknowledgments and understandings of such Purchaser set forth herein in order
to determine the applicability of such exemptions and the suitability of such
Purchaser to acquire the Shares.

 

Article III.     
OTHER AGREEMENTS OF THE PARTIES

 

Section 3.01     Transfer Restrictions.

 

(a)     The Purchasers covenant that the Shares will only be disposed of
pursuant to an effective registration statement under, and in compliance with
the requirements of, the Securities Act or pursuant to an available exemption
from the registration requirements of the Securities Act, and in compliance with
any applicable state securities laws. In connection with any transfer of Shares
other than pursuant to an effective registration statement, the Company may
require the transferor to provide the Company with an opinion of counsel
selected by the transferor, the form and substance of which opinion shall be
reasonably satisfactory to the Company, to the effect that such transfer does
not require registration under the Securities Act.

 

(b)     The Purchasers agree to the imprinting of the following legend on any
certificate evidencing any of the Shares and to the notation of such legend in
the stock books of the Company (in addition to any legend required by applicable
state securities or “blue sky” laws):

 

THESE SECURITIES REPRESENTED BY THIS CERTIFICATE (THE “SECURITIES”) HAVE NOT
BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES
ACT”) OR ANY STATE SECURITIES LAWS AND MAY NOT BE SOLD, TRANSFERRED OR OTHERWISE
DISPOSED OF UNLESS REGISTERED UNDER THE SECURITIES ACT AND UNDER APPLICABLE
STATE SECURITIES LAWS OR THE COMPANY SHALL HAVE RECEIVED AN OPINION OF COUNSEL
THAT REGISTRATION OF SUCH SECURITIES UNDER THE SECURITIES ACT AND UNDER THE
PROVISIONS OF APPLICABLE STATE SECURITIES LAWS IS NOT REQUIRED.

 

Section 3.02     Integration. The Company shall not sell, offer for sale or
solicit offers to buy or otherwise negotiate in respect of any security (as
defined in Section 2 of the Securities Act) that would be integrated with the
offer or sale of the Shares in a manner that would require the registration
under the Securities Act of the sale of the Shares to the Purchasers.

 

Section 3.03     Exchange Right. To the extent that (i) the Company is not
listed on a U.S. national securities exchange by October 31, 2020, or (ii) a
Change of Control (as defined below) occurs, whichever is earlier, each
Purchaser shall have the right to exchange all or any portion of its Shares into
the common stock of the Parent at an exchange ratio of 0.9 shares of the parent
common stock for each one Share. Each Purchaser may exercise the foregoing
exchange right, at its sole election, by sending a written notice to the Company
and the Parent by not later than 3 p.m. local time in New York City, New York on
December 31, 2020. Each Purchaser acknowledges and agrees that by requesting to
exercise its exchange right, it is deemed to remake the representations,
warranties and agreements set forth in

 

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Section 2.02 and Section 3.01 with respect to the acquisition of the Parent
common stock mutatis mutandis. If the aggregate number of shares of Parent
common stock issued to a Purchaser results in a fractional share being issuance,
such fraction of a share shall be rounded up to the nearest whole number. For
the purpose of this Section 3.03, a “Change of Control” means (a) any sale,
lease or transfer or series of sales, leases or transfers of all or
substantially all of the assets of the Company; (b) any sale, transfer or
issuance (or series of sales, transfers or issuances) of capital stock by the
Company or the holders of Common Stock (or other voting stock of the Company)
that results in the inability of the holders of Common Stock (or other voting
stock of the Company) immediately prior to such sale, transfer or issuance to
designate or elect a majority of the board of directors (or its equivalent) of
the Company; or (c) any merger, consolidation, recapitalization or
reorganization of the Company with or into another person (whether or not the
Company is the surviving corporation) that results in the inability of the
holders of Common Stock (or other voting stock of the Company) immediately prior
to such merger, consolidation, recapitalization or reorganization to designate
or elect a majority of the board of directors (or its equivalent) of the
resulting entity.

 

Article IV.     
Miscellaneous

 

Section 4.01     Termination. This Agreement may be terminated by any Purchaser,
as to such Purchaser’s obligations hereunder only and without any effect
whatsoever on the obligations between the Company and the other Purchasers, by
written notice to the other parties, if the Closing has not been consummated on
or before the Termination Date.

 

Section 4.02     Fees and Expenses. Except as otherwise set forth in this
Agreement, each party shall pay the fees and expenses of its advisors, counsel,
accountants and other experts, if any, and all other expenses, incurred by such
party incident to the negotiation, preparation, execution, delivery and
performance of this Agreement. The Company shall pay all stamp or other similar
taxes and duties levied in connection with issuance of the Shares or Parent
common stock pursuant hereto.

 

Section 4.03     Specific Enforcement, Consent to Jurisdiction.

 

(a)     The Parties acknowledge and agree that irreparable damage would occur in
the event that any of the provisions of this Agreement were not performed in
accordance with their specific terms or were otherwise breached. It is
accordingly agreed that the parties shall be entitled to seek an injunction or
injunctions to prevent or cure breaches of the provisions of this Agreement and
to enforce specifically the terms and provisions hereof, this being in addition
to any other remedy to which any of them may be entitled by law or equity.

 

(b)     Each Party (i) hereby irrevocably submits to the jurisdiction of the
United States District Court sitting in the Southern District of New York and
the courts of the State of New York located in New York County for the purposes
of any suit, action or proceeding arising out of or relating to this Agreement
or the transactions contemplated hereby and (ii) hereby waives, and agrees not
to assert in any such suit, action or proceeding, any claim that it is not
personally subject to the jurisdiction of such court, that the suit, action or
proceeding is brought in an inconvenient forum or that the venue of the suit,
action or proceeding is improper. Each Party consents to process being served in
any such suit, action or proceeding by mailing a copy thereof to such party at
the address in effect for notices to it under this Agreement and agrees that
such service shall constitute good and sufficient service of process and notice
thereof. Nothing in this Section 4.03 shall affect or limit any right to serve
process in any other manner permitted by law.

 

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Section 4.04     Entire Agreement; Amendment. This Agreement (including all
exhibits and schedules hereto) contains the entire understanding and agreement
of the parties with respect to the matters covered hereby and, except as
specifically set forth herein, no Party hereto makes any representations,
warranty, covenant or undertaking with respect to such matters and they
supersede all prior understandings and agreements with respect to said subject
matter, all of which are merged herein. No provision of this Agreement may be
waived or amended other than by a written instrument signed by the Company, the
Parent and the Purchasers Holding a majority of the Shares then outstanding and
held by Purchasers. No such amendment shall be effective to the extent that it
applies to less than all of the holders of the Shares then outstanding.

 

Section 4.05     Notices. Any notice, demand, request, waiver or other
communication required or permitted to be given hereunder shall be in writing
and shall be effective (a) upon hand delivery by telex (with correct answer back
received), telecopy, e-mail or facsimile at the address or number designated
below (if delivered on a business day during normal business hours where such
notice is to be received), or the first business day following such delivery (if
delivered other than on a business day during normal business hours where such
notice is to be received) or (b) on the second business day following the date
of mailing by express courier service, fully prepaid, addressed to such address,
or upon actual receipt of such mailing, whichever shall first occur. The
addresses for such communications shall be:

 

(a)     If to the Company:

 

NeuroClear Technologies, Inc.

c/o BioSig Technologies, Inc.

12424 Wilshire Blvd., Suite 745

Los Angeles, California

Attention: Kenneth Londoner

Email: klondoner@biosigtech.com

with copies to:

 

Haynes and Boone, LLP

30 Rockefeller Plaza, 26th Floor

New York, New York 10112

Attention: Rick A. Werner, Esq.

Email: rick.werner@haynesboone.com

Fax No.: (212) 884-8234

 

(b)     If to any Purchaser at the address of such Purchaser set forth on the
signature pages hereto.

 

Any party hereto may from time to time change its address for notices by giving
at least ten (10) days written notice of such changed address to the other party
hereto.

 

Section 4.06     Waivers. No waiver by a party of any default with respect to
any provision, condition or requirement of this Agreement shall be deemed to be
a continuing waiver in the future or a waiver of any other provisions, condition
or requirement hereof, nor shall any delay or omission of any party to exercise
any right hereunder in any manner impair the exercise of any such right accruing
to it thereafter.

 

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Section 4.07     Headings. The article, section and subsection headings in this
Agreement are for convenience only and shall not constitute a part of this
Agreement for any other purpose and shall not be deemed to limit or affect any
of the provisions hereof.

 

Section 4.08     Successors and Assigns; Restrictions on Transfer. This
Agreement shall be binding upon and inure to the benefit of the parties and
their successors and assigns. Neither the Company nor Parent may not assign this
Agreement or any rights or obligations hereunder without the prior written
consent of the Purchasers.

 

Section 4.09     No Third Party Beneficiaries. This Agreement is intended for
the benefit of the parties hereto and their respective permitted successors and
assigns and is not for the benefit of, nor may any provision hereof be enforced
by, any other person.

 

Section 4.10     Governing Law. This Agreement shall be governed by and
construed in accordance with the internal laws of the State of New York, without
giving effect to any of the conflicts of law principles which would result in
the application of the substantive law of another jurisdiction. This Agreement
shall not be interpreted or construed with any presumption against the party
causing this Agreement to be drafted. Each party hereby irrevocably waives, to
the fullest extent permitted by applicable law, any and all rights to a trial by
jury in any legal proceeding arising out of or relating to this Agreement or the
transactions contemplated hereby.

 

Section 4.11     Counterparts. This Agreement may be executed in any number of
counterparts, each of which when so executed shall be deemed to be an original
and, all of which taken together shall constitute one and the same Agreement and
shall become effective when counterparts have been signed by each party and
delivered to the other parties hereto, it being understood that all parties need
not sign the same counterpart. In the event that any signature is delivered by
facsimile transmission, such signature shall create a valid binding obligation
of the party executing (or on whose behalf such signature is executed) the same
with the same force and effect as if such facsimile signature were the original
thereof.

 

Section 4.12     Severability. The provisions of this Agreement are severable
and, in the event that any court of competent jurisdiction shall determine that
any one or more of the provisions or part of the provisions contained in this
Agreement shall, for any reason, be held to be invalid, illegal or unenforceable
in any respect, such invalidity, illegality or unenforceability shall not affect
any other provision or part of a provision of this Agreement and such provision
shall be reformed and construed as if such invalid or illegal or unenforceable
provision, or part of such provision, had never been contained herein, so that
such provisions would be valid, legal and enforceable to the maximum extent
possible.

 

Section 4.13     Further Assurances. From and after the date of this Agreement,
upon the request of any Purchaser or the Company, each of the Company and the
Purchasers shall execute and deliver such instrument, documents and other
writings as may be reasonably necessary or desirable to confirm and carry out
and to effectuate fully the intent and purposes of this Agreement.

 

Section 4.14     Like Treatment of Purchasers. No consideration shall be offered
or paid to any Purchaser to amend or consent to a waiver or modification of any
provision of this Agreement unless the same consideration is also offered to all
of the Purchasers then holding Shares. Further, the Company shall not make any
payments or issue any securities to the Purchasers in amounts which are
disproportionate to the respective numbers of outstanding Shares held by any
Purchasers at any applicable time. For clarification purposes, this provision
constitutes a separate right granted to each Purchaser by the Company and
negotiated separately by each Purchaser, and is intended for the Company to
treat the Purchasers as a class and shall not in any way be construed as the
Purchasers acting in concert or as a group with respect to the purchase,
disposition or voting of the Shares or otherwise.

 

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[SIGNATURE PAGES FOLLOWS]

 

 

 

 

 

 

 

 

 

 

 

 

 

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Company Signature Page

 

IN WITNESS WHEREOF, the Company has caused this Agreement to be duly executed by
an authorized signatory as of the date first above written.

 

 

NEUROCLEAR TECHNOLOGIES, INC.

 

 

By:___________________________________

    Name: Kenneth Londoner

    Title: Chief Executive Officer

 

 

BIOSIG TECHNOLOGIES, INC.,

with respect to 3.03 and Article IV

 

 

By:___________________________________

     Name: Kenneth Londoner

     Title: Executive Chairman

 

 

 

 

 

 

 

 

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Purchaser Signature Page

 

By its execution and delivery of this signature page, the undersigned Purchaser
hereby joins in and agrees to be bound by the terms and conditions of the
Securities Purchase Agreement dated as of [●], 2019 (the “Purchase Agreement”)
by and among NeuroClear Technologies, Inc. and the Purchasers (as defined
therein), as to the number of shares of Common Stock set forth below, and
authorizes this signature page to be attached to the Purchase Agreement or
counterparts thereof.

 

 

 

Name of Purchaser:                                                              
                                                         

 

Signature:                                                                      
                                                           

 

If Entity:          Name                                                        
                                

 

Title                                                                          
                

 

Address:                                                                        
                                        

 

                                                                               
                  

 

                                                                               
                  

 

Telephone No.:                                                                  
                                     

 

Email Address:                                                                  
                                

 

Number of Shares:                                                               
         

 

Aggregate Purchase Price: $                                                     
    

 

SSN/EIN:                                                                       
               

 

Delivery Instructions (if different than above):

 

c/o: __________________________________________________________

 

Address: ______________________________________________________

 

______________________________________________________________

 

Telephone No.: _________________________________________________

 

AGREED AND ACCEPTED BY NEUROCLEAR TECHNOLOGIES, INC.

 

 

By: __________________________________________  Date:                          
                               Name:                                            
                                    Title: