EXHIBIT 10.5
 
HEALTHWAREHOUSE.COM, INC.

CONVERTIBLE NOTE
SUBSCRIPTION AGREEMENT

This Agreement, dated as of April __, 2009, is made and entered into between
HealthWarehouse.com, Inc., a Delaware corporation (the “Company”), and
[___________________] (the “Investor”). This Agreement is entered into in
contemplation of the consummation of a share exchange transaction (the “Exchange
Transaction”) as a result of which (i) the Company will become a wholly-owned
subsidiary of a publicly-traded shell company (“Pubco”), and (ii) the
outstanding shares of capital stock of the Company will be exchanged for
outstanding shares of common stock of Pubco (the “Post-Exchange Common Stock”).
It is contemplated that as a result of the Exchange Transaction, the former
stockholders of the Company will own approximately 85% of Pubco’s Post-Exchange
Common Stock on a fully-diluted basis (and including the shares which may be
issued to the Investor pursuant to the “Securities” as hereafter defined). This
Agreement sets forth the terms under which the Investor will purchase from the
Company a Convertible Promissory Note in the principal amount of $[_________] in
the form attached hereto (the “Note” or the “Securities”) for a purchase price
of $[__________] (the “Purchase Price”) as set forth below.  Upon closing of the
Exchange Transaction (the “Exchange Date”), Pubco (as successor to the Company)
will assume the Company’s rights and obligations under this Agreement.

NOTICE TO INVESTOR: THE SECURITIES PURCHASED HEREBY HAVE NOT BEEN REGISTERED
UNDER THE SECURITIES ACT OF 1933 OR ANY APPLICABLE STATE SECURITIES LAWS. SUCH
SECURITIES MAY BE NOT OFFERED, SOLD, TRANSFERRED, PLEDGED OR HYPOTHECATED IN THE
ABSENCE OF A REGISTRATION UNDER THE SECURITIES ACT OF 1933 AND APPLICABLE STATE
SECURITIES LAWS OR EXEMPTION THEREFROM. FURTHER RESTRICTIONS ON TRANSFERABILITY
OF THE SECURITES ARE CONTAINED IN THIS AGREEMENT.

1.           Subscription.  Subject to the terms of this Agreement, the Investor
hereby subscribes for the Securities, and will tender the Purchase Price in the
form of a certified check or bank check or wired funds payable to
“HealthWarehouse.com, Inc.” as set forth in Section 1.1 below:

1.1           On or before the date hereof, the Investor will pay the
$[___________] Purchase Price, which will be deposited into a segregated account
at JP Morgan Chase Bank, ABA# 044000037 Account #2918186699 (the “Segregated
Account”), and will be issued the Note. The Company agrees that such funds will
be held by the Company in the Segregated Account and will not be used by the
Company for any purpose until the Exchange Transaction is consummated. If the
Exchange Transaction is consummated, the funds in the Segregated Account will be
automatically and immediately released to the Company for use. If the Exchange
Transaction is not consummated by May 15, 2009, the Company will return such
funds to Investor with interest within five (5) business days after May 15,
2009, and this Agreement shall be automatically terminated and cancelled.

 
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1.2           The Company agrees, not later than ninety (90) days after the
Exchange Date, to file a registration statement (the “Registration Statement”)
covering the public resale of all the shares of Post-Exchange Common Stock
issuable pursuant to conversion of the Note (the “Conversion Shares” or the
“Registrable Shares”), and to use its best efforts to cause the Registration
Statement to be declared effective by the U.S. Securities and Exchange
Commission as soon as practicable thereafter. The Company will use its best
efforts to keep the Registration Statement continuously effective under the
Securities Act of 1933, as amended (the “1933 Act”), until the one year
anniversary of the date Pubco files a “jumbo” current report on Form 8-K
describing the Exchange Transaction (which is to be filed within four (4)
business days of the Exchange Date).  Upon the effectiveness of the Registration
Statement and conversion of the Note, the Investor may request that the Company
remove the restrictive legend from the Registrable Shares; provided such
Registrable Shares are registered and sold pursuant to an effective registration
statement.

1.3           If the Registration Statement is not filed within ninety (90) days
after the Exchange Date, as the Investor’s exclusive remedy, the Company shall
pay to the Investor an amount in cash, as liquidated damages and not as a
penalty, equal to 1% of the Purchase Price paid by the Investor for the
Securites. The parties to this Agreement have agreed that the precise amount of
damages in such circumstances would be extremely difficult to calculate
accurately and believe that such amount is a reasonable estimate under the
circumstances existing at this time. Notwithstanding anything herein to the
contrary, if the Regisration Statement is not filed or filed later than (90)
days after the Exchange Date as a result of a material act or omission by the
Investor, the Company shall not be liable to pay liquidated damages to the
Investor that otherwise would result on account of such non-filing or delayed
filing.

2.           Representations and Warranties of Investor. The Investor is making
the following representations, warranties and agreements with the intent that
they be relied upon in determining his suitability to purchase the Securities,
and the Investor agrees that such representations, warranties and agreements
shall survive the date of this Agreement and his purchase of the Securities.
Investor hereby represents and warrants to, and agrees with, the Company, and
each of its officers, directors, persons who control the Company and affiliates
of the foregoing, as follows:

2.1           The Investor has signed and properly and fully completed the
Investor Qualification Statement attached to this Agreement. All of the answers,
statements and information set forth in the Investor Qualification Statement are
true and correct.

2.2           The Investor is (i) if a natural person, at least twenty-one (21)
years of age, and (ii) a bona fide permanent resident of and is domiciled in the
state shown in the address line of the Investor’s signature page to this
Agreement, and has no present intention of becoming a resident of any other
state or jurisdiction.

 
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2.3           The Investor has read and fully considered the sections entitled
“Risk Factors” and “Notices to Investors” in the Company’s Confidential Private
Placement Memorandum dated March 26, 2009 (which, together with the exhibits to
such memorandum, and all supplements to such memorandum, is referred to as the
“Memorandum” in this Agreement).

2.4           The Investor has such knowledge and experience in financial and
business matters that the Investor is capable of evaluating the merits and risks
of an investment in the Securities and of making an informed investment
decision, and is not utilizing any other person to be the Investor’s
representative in connection with evaluating such merits and risks.

2.5           The Investor is acquiring the Securities for his own account, for
investment purposes only, and not with a view toward the resale, resyndication,
distribution, subdivision or fractionalization thereof, and has no present
intention of selling or transferring or otherwise distributing the same. The
Investor has no need for liquidity in this investment, has the ability to bear
the economic risk of this investment, at the present time and in the foreseeable
future, can afford a complete loss of this investment, and this investment
constitutes an appropriate investment for and is not in violation of any
investment restrictions (whether by statute, contract or otherwise) binding upon
the Investor.

2.6           In making an investment in the Securities, the Investor
acknowledges that no oral representations or warranties have been made to the
Investor. The Investor has received and carefully read a copy of the Memorandum.
In making the decision to invest in the Securities, the Investor has relied
solely on the information in the Memorandum. The Investor has been advised that
no person is authorized to give any information or make any statement not
contained in the Memorandum, and that any information or statement not contained
therein must not be relied upon as having been authorized by the Company, its
officers, directors, affiliates or persons who control the Company.

2.7           The Investor is aware that all documents, records and books
pertaining to this investment are available at the offices of the Company at 100
Commerce Blvd., Cincinnati, OH 45140, and acknowledges that all documents,
records and books pertaining to this investment requested by the Investor have
been made available to the Investor and the persons the Investor has retained,
if any, to advise him with respect to this investment, and the Investor and such
persons have been supplied with such additional information concerning this
investment as has been requested.

2.8           The Investor has been given the opportunity to discuss his
investment in, and the operation of, the Company with the Company’s management
and has been given all information that the Investor has requested and which the
Investor deems relevant to his decision to invest in the Company. The Investor
has consulted such legal, financial and tax advisers as have been necessary to
evaluate the merits and risks of this investment. The Investor acknowledges and
is aware that the Company has a limited financial and operating history.

2.9           The Investor agrees that the Securities (including any interest
therein) will not be sold or otherwise disposed of by the Investor unless either
(i) the sale or other disposition will be pursuant to a registration statement
under 1933 Act, and any applicable securities laws of any state or other
jurisdiction; or (ii) the Investor shall have notified the Company in writing of
any desire on the part of the Investor to sell or dispose of all or part of the
such Securities and of the manner and terms of the proposed transaction, and the
Company shall have been advised in writing by counsel acceptable to it that no
registration of such Securities under the 1933 Act, or the rules and regulations
then in effect thereunder, or any applicable state securities laws, is required
in connection with the proposed sale or other disposition. Except as provided in
Section 1.3, the Investor acknowledges that the Company is under no obligation
whatsoever in connection with any such registration or exemption. The Investor
acknowledges that all certificates evidencing ownership of the Securities, or
any replacement thereof, shall bear an appropriate legend to the effect that the
securities evidenced by such certificate or instruments are subject to these
terms.

 
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2.10           All information provided by the Investor to the Company is true
and correct in all respects as of the date hereof, and if there should be any
material change in such information either prior to the Company accepting the
Investor’s subscription or thereafter, the Investor will immediately furnish
such revised or corrected information to the Company.

2.11           The Investor understands that no federal or state agency has
passed on or made any recommendation or endorsement of the Securities and that
the Company is relying on the truth and accuracy of the representations
warranties and agreements made by him in offering the Securities for sale to him
without having first registered the same under the 1933 Act.

2.12           The Investor represents that he has not distributed the
Memorandum to anyone other than his personal advisers for their review on his
behalf, and that no one other than his personal advisers have used the
Memorandum for any purpose.

2.13           The Investor acknowledges that there have been no
representations, guarantees or warranties made to him by the Company, its
officers, directors, controlling persons, agents or employees or any other
person, expressly or by implication, with respect to the amount of or type of
consideration, profit or loss (including tax benefits) to be realized, if any,
as a result of his investment.

3.           Indemnification. The Investor agrees to indemnify and hold harmless
the Company and its directors and officers, their affiliates or anyone acting on
behalf of the Company from and against any and all damages, losses, costs and
expenses (including reasonable attorneys, fees) which they may incur by reason
of the failure of Investor to fulfill any of the terms or conditions of this
Agreement, or by reason of any breach of the representations and warranties made
by the Investor herein, or in any document provided by the Investor to the
Company.

4.           Transferability. The Investor agrees that he shall not transfer or
assign this Agreement or any interest herein, and any such transfer or
assignment purported to be made shall be null and void and of no effect.
Pursuant to the Exchange Transaction, the Company will transfer and assign this
Agreement and any interest herein to Pubco.

 
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5.           General Provisions.

5.1           This Agreement constitutes the entire agreement between the
parties and supersedes and cancels any other agreement, or representation or
communication other than the Memorandum, whether oral or written, between the
parties relating to the transactions contemplated herein or the subject matter
hereof.

5.2           This Agreement may be executed in more than one counterpart which
shall, in the aggregate, be deemed to be the original instrument and agreement
between the parties, and copies signed and transmitted electronically in a form
readable by the recipient or by facsimile are as binding as if the original was
signed in person.

5.3           Any and all notices or other communications required or permitted
by this Agreement or by law to be served on or given to any party hereto by any
other party hereto shall be, unless otherwise required by law, in writing and
deemed duly served and given when actually received either (i) in an electronic
form readable by the recipient, or (ii) when delivered by facsimile, or (iii)
when delivered by hand, by recognized express delivery services or via the
United States mail, certified or registered, return, receipt requested, postage
prepaid, addressed to the Company at its principal offices at 100 Commerce
Blvd., Cincinnati, OH 45140, and to the Investor at its address as set forth on
the signature page to this Agreement or otherwise transmitted to the Company
from time to time.

5.4           No term hereof may be changed, waived, discharged or terminate
orally, but only by an instrument in writing signed by the party against which
enforcement of the change, waiver, discharge or termination is sought.

5.5           The headings in this Agreement are for the purposes and
convenience of reference only and shall not be deemed to constitute a part
hereof.

5.6           This Agreement shall be construed and enforced in accordance with
and governed by the laws of the State of Delaware, without reference to its
principles of conflict of laws. Any action to enforce the terms of this
Agreement shall be brought in a court of competent jurisdiction located in
Hamilton County, Ohio.

5.7           The benefits of this Agreement shall inure, and the obligations of
this Agreement shall be binding upon, the personal representatives, heirs,
legatees, permitted successors and assigns of the parties hereto.

5.8           The Investor agrees that the Investor may not cancel, terminate,
or revoke this Agreement or any agreement of the Investor made hereunder.

5.9           Except as otherwise provided in this Agreement, each party to this
Agreement shall pay any and all fees and expenses that such party may incur in
connection with the negotiation, execution and closing of the transactions
contemplated by this Agreement.

(Signatures start on next page)
 
 
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HEALTHWAREHOUSE.COM, INC.
SUBSCRIPTION AGREEMENT
SIGNATURE PAGE

IN WITNESS WHEREOF, the Investor has executed this Subscription Agreement on the
date indicated below.
 

                   
NAME of Subscriber  (print/type)
   
NAME of Subscriber  (print/type)
 
 
   
 
                     
Authorized SIGNATURE of Subscriber
   
Authorized SIGNATURE of Subscriber
                               
Address
   
Address
                               
City    State    Zip
   
City    State    Zip
                               
Home Telephone
   
Home Telephone
                               
Business Telephone
   
Business Telephone
                                Social Security Number     Social Security
Number                      
Date Signed: ________________________
   
Date Signed: ________________________
 

 
 
If the Investor is a corporation, partnership, trust or other entity, or is
otherwise acting as a fiduciary, the name and capacity (title) of the individual
executing this Agreement on the Investor’s behalf should be printed or typed
below the signature.
 
 
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PLEASE SUPPLY THE FOLLOWING INFORMATION:

Manner in which title is to be held; (Check one)

___  Individual Ownership
   
___  Partnership*
           
___  Individual Retirement Account
   
___  Trust *
 
 
       
___  Qualified Retirement Plan
   
___  Corporation*
            ___  Other:    
___  Limited Liability Company*
                               
(Please indicate)
       

 
 
*
In the case of a partnership, state names of all partners and attach a copy of
the partnership agreement. In the case of a corporation, attach a copy of the
articles of incorporation together with the resolution of the board of directors
authorizing this investment. In the case of a limited liability company, attach
a copy of the articles of organization and operating agreement and a copy of any
required member or manager resolutions authorizing this investment. In the case
of a trust, attach a copy of the trust agreement.

 
 
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ACCEPTANCE

HealthWarehouse.com, Inc. hereby accepts and agrees to be bound by the foregoing
subscription subject to the terms and conditions hereof as of the date indicated
below.
 

        HEALTHWAREHOUSE.COM, INC.                
 
By:
              Name:               Title:               Date Signed:    

 
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