PG - Filed by Filing Services Canada Inc. (403) 717-3898


SUBSCRIPTION AGREEMENT


 


THIS SUBSCRIPTION AGREEMENT (this “Agreement”) is made as of the last date set forth on the signature page hereof betweenGreen PolkaDot Box Incorporated, a Nevadacorporation(the “Company”) and the undersigned (the “Subscriber”).


 


WITNESSETH:


 


WHEREAS, the Company is conducting a private placement offering of units (the “Units”, and the transaction, the “Offering”)  with each Unit consisting of one share of common stock, par value $0.001 per share (the “Shares”) and one five-year warrant substantially in the form attached hereto as Exhibit A (the “Warrants”) to purchase the number of Shares purchased in the Offering with an exercise price of $4.50 per share for sale to accredited investors at a price of $3.00 per Unit (the “Offering Price “) pursuant to Section 4(2) of the Securities Act of 1933, as amended (the “Securities Act”); and


 


WHEREAS, the Subscriber desires to purchase that number of Units set forth on the signature page hereof on the terms and conditions hereinafter set forth.


 


NOW, THEREFORE, in consideration of the premises and the mutual representations and covenants hereinafter set forth, the parties hereto do hereby agree as follows:


 



	
I.  

	
SUBSCRIPTION FOR UNITS AND REPRESENTATIONS BY SUBSCRIBER







 


1.1 Subject to the terms and conditions hereinafter set forth the Subscriber hereby irrevocably subscribes for and agrees to purchase from the Company such number of Units, and the Company agrees to sell to the Subscriber, as is set forth on the signature page hereof, at a per Unit price equal to $3.00 per Unit.  Within a commercially reasonable time after the execution and delivery of this Agreement, the Subscriber shall wire the aggregate Offering Price to be held in escrow in accordance with the terms of the Escrow Agreement substantially in the form attached asExhibit B (the “Escrow Agreement”).  The Subscriber understands and agrees that, subject to Section 2 and applicable laws, by executing this Agreement, it is entering into a binding agreement.  The aggregate Offering Price is payable by wire transfer of immediately available funds to:


 


Wire instructions:







Bank:                                     Citibank


New York, NY



	
  

	
A/C of

	
Sichenzia Ross Friedman Ference LLP







A/C#:                                      92883436


ABA#:                                    021000089


SWIFT Code:                        CITIUS33


 


REFERENCE:                       GREEN POLKADOT BOX


 




  





 











  











1.2   Closing.  The closing of the purchase and sale of the Units hereunder (the “Closing”) shall take place at the offices of Sichenzia Ross Friedman Ference LLP, 61 Broadway, 32nd Floor, New York, NY 10006 or such other place as determined by the Company.  The Closing shall take place on a Business Day promptly following the satisfaction of the conditions set forth in Article IV below, as determined by the Company (the “Closing Date”). “Business Day” shall mean from the hours of 9:00 a.m. (Eastern Time) through 5:00 p.m. (Eastern Time) of a day other than a Saturday, Sunday or other day on which commercial banks in New York, New York are authorized or required to be closed. The Shares and Warrants purchased by the Subscriber will be delivered by the Company promptly following the Closing.  At the Closing, the Company shall deliver to the Subscriber an irrevocable instruction letter to the transfer agent instructing the transfer agent to deliver the Shares.


 


1.3   The Subscriber recognizes that the purchase of the Units involves a high degree of risk including, but not limited to, the following: (a) the Company has limited operating history and requires substantial funds in addition to the proceeds of the Offering; (b) an investment in the Company is highly speculative, and only investors who can afford the loss of their entire investment should consider investing in the Company and the Units; (c) the Subscriber may not be able to liquidate its investment; (d) transferability of the Units is extremely limited; (e) in the event of a disposition, the Subscriber could sustain the loss of its entire investment; (f) the Company has not paid any dividends since its inception and does not anticipate paying any dividends in the foreseeable future; and (g) the Company may issue additional securities in the future which have rights and preferences that are senior to those of the Shares.  Without limiting the generality of the representations set forth in Section 1.5and 1.6 below, the Subscriber represents that the Subscriber has carefully reviewed the Company’s reports and filings with the SEC, including without limitation, the Company’s Current Report on Form 8-K filed on March 6, 2012, including the information and risks provided under the section captioned “Risk Factors.”  The reports and filings of the Company are available on the SEC’s website at www.sec.gov.


 


1.4   The Subscriber represents that the Subscriber is an “accredited investor” as such term is defined in Rule 501 of Regulation D (“Regulation D”) promulgated under the Securities Act, as indicated by the Subscriber’s responses to the questions contained in Article VI hereof, and that the Subscriber is able to bear the economic risk of an investment in the Units.


 


1.5   The Subscriber hereby acknowledges and represents that (a) the Subscriber has knowledge and experience in business and financial matters, prior investment experience, including investment in securities that are non-listed, unregistered and/or not traded on a national securities exchange, or the Subscriber has employed the services of a “purchaser representative” (as defined in Rule 501 of Regulation D), attorney and/or accountant to read all of the documents furnished or made available by the Company both to the Subscriber and to all other prospective investors in the Units to evaluate the merits and risks of such an investment on the Subscriber’s behalf; (b) the Subscriber recognizes the highly speculative nature of this investment; and (c) the Subscriber is able to bear the economic risk that the Subscriber hereby assumes.


 




  





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1.6   The Subscriber hereby acknowledges receipt and careful review of this Agreement, the Company’s reports and filings with the SEC (which reports and filings include“Risk Factors”), including all exhibits thereto, and any documents which may have been made available upon request as reflected therein (collectively referred to as the “Offering Materials”) and hereby represents that the Subscriber has been furnished by the Company during the course of the Offering with all information regarding the Company, the terms and conditions of the Offering and any additional information that the Subscriber has requested or desired to know, and has been afforded the opportunity to ask questions of and receive answers from duly authorized officers or other representatives of the Company concerning the Company and the terms and conditions of the Offering.


 


1.7   (a)           In making the decision to invest in the Units the Subscriber has relied solely upon the information provided by the Company in the Offering Materials.  To the extent necessary, the Subscriber has retained, at its own expense, and relied upon appropriate professional advice regarding the investment, tax and legal merits and consequences of this Agreement and the purchase of the Units hereunder.  The Subscriber disclaims reliance on any statements made or information provided by any person or entity in the course of Subscriber’s consideration of an investment in the Units other than the Offering Materials.


 


(b)           The Subscriber represents and warrants that (i) the Subscriber was contacted regarding the sale of the Units by the Company (or an authorized agent or representative thereof) with whom the Subscriber had a prior substantial pre-existing relationship and (ii) no Units were offered or sold to it by means of any form of general solicitation or general advertising, and in connection therewith, the Subscriber did not (A) receive or review any advertisement, article, notice or other communication published in a newspaper or magazine or similar media or broadcast over television or radio, whether closed circuit, or generally available; or (B) attend any seminar meeting or industry investor conference whose attendees were invited by any general solicitation or general advertising; or (C) observe any website or filing of the Company in which any offering of securities by the Company was described and as a result learned of any offering of securities by the Company.


 


1.8   The Subscriber hereby represents that the Subscriber, either by reason of the Subscriber’s business or financial experience or the business or financial experience of the Subscriber’s professional advisors (who are unaffiliated with and not compensated by the Company or any affiliate or selling agent of the Company, directly or indirectly), has the capacity to protect the Subscriber’s own interests in connection with the transaction contemplated hereby.


 


1.9   The Subscriber hereby acknowledges that the Offering has not been reviewed by the United States Securities and Exchange Commission (the “SEC”) nor any state regulatory authority since the Offering is intended to be exempt from the registration requirements of Section 5 of the Securities Act, pursuant to Regulation D.  The Subscriber understands that the Units have not been registered under the Securities Act or under any state securities or “blue sky” laws and agrees not to sell, pledge, assign or otherwise transfer or dispose of the Units unless they are registered under the Securities Act and under any applicable state securities or “blue sky” laws or unless an exemption from such registration is available.


 




  





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1.10   The Subscriber understands that the Units have not been registered under the Securities Act by reason of a claimed exemption under the provisions of the Securities Act that depends, in part, upon the Subscriber’s investment intention.  In this connection, the Subscriber hereby represents that the Subscriber is purchasing the Units for the Subscriber’s own account for investment and not with a view toward the resale or distribution to others.  The Subscriber, if an entity, further represents that it was not formed for the purpose of purchasing the Units.


 


1.11   The Subscriber understands that there is a limited trading market for the Company’s common stock (the “Common Stock”) and that an active market may not develop for the Common Stock.  The Subscriber understands that even if an active market develops for the Common Stock, Rule 144 promulgated under the Securities Act requires for non-affiliates (“Rule 144”), among other conditions, a one-year holding period commencing as of the date that the Company files “Form 10 information” with the SEC, prior to the resale of securities acquired in a non-public offering without having to satisfy the registration requirements under the Securities Act.  The Subscriber understands and hereby acknowledges that the Company is under no obligation to register any of the Shares, the Warrant Shares, or the Warrants under the Securities Act or any state securities or “blue sky” laws.


 


1.12   The Subscriber consents to the placement of a legend on any certificate or other document evidencing the Units (including, the underlying Shares, Warrants and common stock underlying the Warrants) that such Units have not been registered under the Securities Act or any state securities or “blue sky” laws and setting forth or referring to the restrictions on transferability and sale thereof contained in this Agreement.  The Subscriber is aware that the Company will make a notation in its appropriate records with respect to the restrictions on the transferability of such Units. The legend to be placed on each certificate shall be in form substantially similar to the following:


 


“The securities represented by this certificate have not been registered under the Securities Act of 1933, as amended and may not be sold, transferred, pledged, hypothecated or otherwise disposed of in the absence of (i) an effective registration statement for such securities under said act or (ii) an opinion of company counsel that such registration is not required.”







1.13   The Subscriber understands that the Company will review this Agreement and is hereby given authority by the Subscriber to call Subscriber’s bank or place of employment or otherwise review the financial standing of the Subscriber; and it is further agreed that the Company, at its sole discretion, reserves the unrestricted right, without further documentation or agreement on the part of the Subscriber, to reject or limit any subscription, to accept subscriptions for fractional Units and to close the Offering to the Subscriber at any time and that the Company will issue stop transfer instructions to its transfer agent with respect to such Units.


 


1.14         The Subscriber hereby represents that the address of the Subscriber furnished by Subscriber on the signature page hereof is the Subscriber’s principal residence if Subscriber is an individual or its principal business address if it is a corporation or other entity.


 




  





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1.15   The Subscriber represents that the Subscriber has full power and authority (corporate, statutory and otherwise) to execute and deliver this Agreement and to purchase the Units.  This Agreement constitutes the legal, valid and binding obligation of the Subscriber, enforceable against the Subscriber in accordance with its terms.


 


1.16   If the Subscriber is a corporation, partnership, limited liability company, trust, employee benefit plan, individual retirement account, Keogh Plan, or other tax-exempt entity, it is authorized and qualified to invest in the Company and the person signing this Agreement on behalf of such entity has been duly authorized by such entity to do so.


 


1.17   The Subscriber acknowledges that if he or she is a Registered Representative of a Financial Industry Regulatory Authority (“FINRA”) member firm, he or she must give such firm the notice required by the FINRA’s Rules of Fair Practice, receipt of which must be acknowledged by such firm in Section 6.4 below.


 


1.18   The Subscriber acknowledges that at such time, if ever, as the Units are registered, sales of the Units will be subject to state securities laws.


 


1.19   (a)           The Subscriber agrees not to issue any public statement with respect to the Subscriber’s investment or proposed investment in the Company or the terms of any agreement or covenant between them and the Company without the Company’s prior written consent, except such disclosures as may be required under applicable law or under any applicable order, rule or regulation.


 


  (b) The Company agrees not to disclose the names, addresses or any other information about the Subscribers, except as required by law; provided, that the Company may use the name of the Subscriber for any offering or in any registration statement filed pursuant to Article V in which the Subscriber’s Units are included.


 


1.20   The Subscriber agrees to hold the Company and its directors, officers, employees, affiliates, controlling persons and agents and their respective heirs, representatives, successors and assigns harmless and to indemnify them against all liabilities, costs and expenses incurred by them as a result of (a) any sale or distribution of the Units by the Subscriber in violation of the Securities Act or any applicable state securities or “blue sky” laws; or (b) any false representation or warranty or any breach or failure by the Subscriber to comply with any covenant made by the Subscriber in this Agreement (including the Confidential Investor Questionnaire contained in Article VII herein) or any other document furnished by the Subscriber to any of the foregoing in connection with this transaction.


 



	
II.  

	
REPRESENTATIONS BY AND COVENANTS OF THE COMPANY







 


The Company hereby represents and warrants to the Subscriber that:


 


2.1   Organization, Good Standing and Qualification.  The Company is a corporation duly organized, validly existing and in good standing under the laws of the State of Nevadaand has full corporate power and authority to conduct its business.


 




  





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2.2   Authorization; Enforceability.  The Company has all corporate right, power and authority to enter into this Agreement and to consummate the transactions contemplated hereby.  All corporate action on the part of the Company, its directors and stockholders necessary for the (a) authorization execution, delivery and performance of this Agreement by the Company; and (b) authorization, sale, issuance and delivery of the Units contemplated hereby and the performance of the Company’s obligations hereunder has been taken.  This Agreement has been duly executed and delivered by the Company and constitutes a legal, valid and binding obligation of the Company, enforceable against the Company in accordance with its terms, subject to laws of general application relating to bankruptcy, insolvency and the relief of debtors and rules of law governing specific performance, injunctive relief or other equitable remedies, and to limitations of public policy.  The Units, when issued and fully paid for in accordance with the terms of this Agreement, will be validly issued, fully paid and nonassessable.  The issuance and sale of the Units contemplated hereby will not give rise to any preemptive rights or rights of first refusal on behalf of any person which have not been waived in connection with this offering.


 


2.3   No Conflict; Governmental Consents.


 


(a)   The execution and delivery by the Company of this Agreement and the consummation of the transactions contemplated hereby will not result in the violation of any material law, statute, rule, regulation, order, writ, injunction, judgment or decree of any court or governmental authority to or by which the Company is bound, or of any provision of the Articles of Incorporation or Bylaws of the Company, and will not conflict with, or result in a material breach or violation of, any of the terms or provisions of, or constitute (with due notice or lapse of time or both) a default under, any lease, loan agreement, mortgage, security agreement, trust indenture or other agreement or instrument to which the Company is a party or by which it is bound or to which any of its properties or assets is subject, nor result in the creation or imposition of any lien upon any of the properties or assets of the Company.


 


(b)   No consent, approval, authorization or other order of any governmental authority is required to be obtained by the Company in connection with the authorization, execution and delivery of this Agreement or with the authorization, issue and sale of the Units, except such filings as may be required to be made with the SEC, FINRA, NASDAQ and with any state or foreign blue sky or securities regulatory authority.


 



	
III.  

	
TERMS OF SUBSCRIPTION







 


3.1   All funds paid hereunder shall be deposited with the Company in the account identified in Section 1.1 hereof.


 


3.2            Certificates representing the Shares and Warrants purchased by the Subscriber pursuant to this Agreement will be prepared for delivery to the Subscriber within 15 business days following the closing at which such purchase takes place. The Subscriber hereby authorizes and directs the Company to deliver the certificates representing the Shares and Warrants purchased by the Subscriber pursuant to this Agreement directly to the Subscriber’s residential or business address indicated on the signature page hereto.


 




  





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IV.  

	
CONDITIONS TO OBLIGATIONS OF THE SUBSCRIBERS







 


4.1   The Subscriber’s obligation to purchase the Units at the closing at which such purchase is to be consummated is subject to the fulfillment on or prior to such closing of the following conditions, which conditions may be waived at the option of each Subscriber to the extent permitted by law:


 


(a)   Covenants.  All covenants, agreements and conditions contained in this Agreement to be performed by the Company on or prior to the date of such closing shall have been performed or complied with in all material respects.


 


(b)   No Legal Order Pending.  There shall not then be in effect any legal or other order enjoining or restraining the transactions contemplated by this Agreement.


 


(c)   No Law Prohibiting or Restricting Such Sale.  There shall not be in effect any law, rule or regulation prohibiting or restricting such sale or requiring any consent or approval of any person, which shall not have been obtained, to issue the Units (except as otherwise provided in this Agreement).


 



	
V.  

	
MISCELLANEOUS







 


5.1   Any notice or other communication given hereunder shall be deemed sufficient if in writing and sent by registered or certified mail, return receipt requested, or delivered by hand against written receipt therefor, addressed as follows:


 


if to the Company, at:


Green PolkaDotBox Incorporated


629 East Quality Drive, Suite 103


American Fork, Utah 84003


Attn:  Rod A. Smith, Chief Executive Officer







With a copy to (which shall not constitute notice):







Sichenzia Ross Friedman Ference LLP


61 Broadway, 32nd Floor


New York, NY 10006


Attn:  Andrea Cataneo, Esq.







if to the Subscriber, to the Subscriber’s address indicated on the signature page of this Agreement.


 


Notices shall be deemed to have been given or delivered on the date of mailing, except notices of change of address, which shall be deemed to have been given or delivered when received.


 


5.2   Except as otherwise provided herein, this Agreement shall not be changed, modified or amended except by a writing signed by the parties to be charged, and this Agreementmay not be discharged except by performance in accordance with its terms or by a writing signed by the party to be charged.


 




  





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5.3            Subject to the provisions of Section 5.11, this Agreement shall be binding upon and inure to the benefit of the parties hereto and to their respective heirs, legal representatives, successors and assigns.  This Agreement sets forth the entire agreement and understanding between the parties as to the subject matter hereof and merges and supersedes all prior discussions, agreements and understandings of any and every nature among them.


 


5.4            Upon the execution and delivery of this Agreement by the Subscriber, this Agreement shall become a binding obligation of the Subscriber with respect to the purchase of Units as herein provided, subject, however, to the right hereby reserved by the Company to enter into the same agreements with other subscribers and to add and/or delete other persons as subscribers.


 


5.5   NOTWITHSTANDING THE PLACE WHERE THIS AGREEMENT MAY BE EXECUTED BY ANY OF THE PARTIES HERETO, THE PARTIES EXPRESSLY AGREE THAT ALL THE TERMS AND PROVISIONS HEREOF SHALL BE CONSTRUED IN ACCORDANCE WITH AND GOVERNED BY THE LAWS OF THE STATE OF NEW YORK WITHOUT REGARD TO SUCH STATE’S PRINCIPLES OF CONFLICTS OF LAW.  IN THE EVENT THAT A JUDICIAL PROCEEDING IS NECESSARY, THE SOLE FORUM FOR RESOLVING DISPUTES ARISING OUT OF OR RELATING TO THIS AGREEMENT IS THE COURTS STATE OF NEW YORK IN AND FOR THE COUNTY OF NEW YORK OR THE FEDERAL COURTS FOR SUCH STATE AND COUNTY, AND ALL RELATED APPELLATE COURTS, THE PARTIES HEREBY IRREVOCABLY CONSENT TO THE JURISDICTION OF SUCH COURTS AND AGREE TO SAID VENUE.


 


5.6            In order to discourage frivolous claims the parties agree that unless a claimant in any proceeding arising out of this Agreement succeeds in establishing his claim and recovering a judgment against another party (regardless of whether such claimant succeeds against one of the other parties to the action), then the other party shall be entitled to recover from such claimant all of its/their reasonable legal costs and expenses relating to such proceeding and/or incurred in preparation therefor.


 


5.7   The holding of any provision of this Agreement to be invalid or unenforceable by a court of competent jurisdiction shall not affect any other provision of this Agreement, which shall remain in full force and effect.  If any provision of this Agreement shall be declared by a court of competent jurisdiction to be invalid, illegal or incapable of being enforced in whole or in part, such provision shall be interpreted so as to remain enforceable to the maximum extent permissible consistent with applicable law and the remaining conditions and provisions or portions thereof shall nevertheless remain in full force and effect and enforceable to the extent they are valid, legal and enforceable, and no provisions shall be deemed dependent upon any other covenant or provision unless so expressed herein.


 


5.8            It is agreed that a waiver by either party of a breach of any provision of this Agreement shall not operate, or be construed, as a waiver of any subsequent breach by that same party.


 




  





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5.9           The parties agree to execute and deliver all such further documents, agreements and instruments and take such other and further action as may be necessary or appropriate to carry out the purposes and intent of this Agreement.


 


5.10         This Agreement may be executed in two or more counterparts each of which shall be deemed an original, but all of which shall together constitute one and the same instrument.


 


5.11          Nothing in this Agreement shall create or be deemed to create any rights in any person or entity not a party to this Agreement.


 


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VI.  

	
CONFIDENTIAL INVESTOR QUESTIONNAIRE







 


6.1   The Subscriber represents and warrants that he, she or it comes within one category marked below, and that for any category marked, he, she or it has truthfully set forth, where applicable, the factual basis or reason the Subscriber comes within that category.  ALL INFORMATION IN RESPONSE TO THIS SECTION WILL BE KEPT STRICTLY CONFIDENTIAL.  The undersigned agrees to furnish any additional information which the Company deems necessary in order to verify the answers set forth below.


 



	
Category A

	
The undersigned is an individual (not a partnership, corporation, etc.) whose individual net worth, or joint net worth with his or her spouse, presently exceeds $1,000,000.












Explanation.  In calculating net worth you may include equity in personal property and real estate, including your principal residence, cash, short-term investments, stock and securities.  Equity in personal property and real estate should be based on the fair market value of such property less debt secured by such property.








	
Category B

	
The undersigned is an individual (not a partnership, corporation, etc.) who had an income in excess of $200,000 in each of the two most recent years, or joint income with his or her spouse in excess of $300,000 in each of those years (in each case including foreign income, tax exempt income and full amount of capital gains and losses but excluding any income of other family members and any unrealized capital appreciation) and has a reasonable expectation of reaching the same income level in the current year.













	
Category C

	
The undersigned is a director or executive officer of the Company which is issuing and selling the Units.













	
Category D

	
The undersigned is a bank; a savings and loan association; insurance company; registered investment company; registered business development company; licensed small business investment company (“SBIC”); or employee benefit plan within the meaning of Title 1 of ERISA and (a) the investment decision is made by a plan fiduciary which is either a bank, savings and loan association, insurance company or registered investment advisor, or (b) the plan has total assets in excess of $5,000,000 or (c) is a self directed plan with investment decisions made solely by persons that are accredited investors. (describe entity)







                                                 _____________________________________________________________________________________



                                         _____________________________________________________________________________________


 





	
Category E

	
The undersigned is a private business development company as defined in section 202(a)(22) of the Investment Advisors Act of 1940. (describe entity)





                                                 _____________________________________________________________________________________




                                         _____________________________________________________________________________________


 




  





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Category F

	
The undersigned is either a corporation, partnership, Massachusetts business trust, or non-profit organization within the meaning of Section 501(c)(3) of the Internal Revenue Code, in each case not formed for the specific purpose of acquiring the Units and with total assets in excess of $5,000,000. (describe entity)







                 _____________________________________________________________________________________


                                         _____________________________________________________________________________________


 







	
Category G

	
The undersigned is a trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units, where the purchase is directed by a “sophisticated investor” as defined in Regulation 506(b)(2)(ii) under the Act.







 



	
Category H

	
The undersigned is an entity (other than a trust) in which all of the equity owners are “accredited investors” within one or more of the above categories.  If relying upon this Category alone, each equity owner must complete a separate copy of this Agreement.  (describe entity)







                                                 _____________________________________________________________________________________


                                         _____________________________________________________________________________________


 







	
Category I

	
The undersigned is not within any of the categories above and is therefore not an accredited investor.







 


The undersigned agrees that the undersigned will notify the Company at any time on or prior to the closing in the event that the representations and warranties in this Agreement shall cease to be true, accurate and complete.


 


6.2   SUITABILITY (please answer each question)


 


(a)           For an individual Subscriber, please describe your current employment, including the company by which you are employed and its principal business:


___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


 


(b)           For an individual Subscriber, please describe any college or graduate degrees held by you:


___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


 


(c)           For all Subscribers, please list types of prior investments:



___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


___________________________________________________________________________________________________


 


 




  





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(d)           For all Subscribers, please state whether you have participated in other private placements before:


 


YES_______                                           NO_______


 


(e)           If your answer to question (d) above was “YES”, please indicate frequency of such prior participation in private placements of:


 



	  	 	
 


Public


Companies

	 	
 


Private


Companies

	 	
Public or Private Companies


with no, or insignificant,


assets and operations


 

	 
	
Frequently

	 	  	 	  	 	  	 
	
Occasionally

	 	  	 	 	 	  	 
	
Never

	 	  	 	  	 	  	 










(f)           For individual Subscribers, do you expect your current level of income to significantly decrease in the foreseeable future:


 


YES_______                                           NO_______


 


(g)           For trust, corporate, partnership and other institutional Subscribers, do you expect your total assets to significantly decrease in the foreseeable future:


 


YES_______                                           NO_______


 


(h)           For all Subscribers, do you have any other investments or contingent liabilities which you reasonably anticipate could cause you to need sudden cash requirements in excess of cash readily available to you:


 


YES_______                                           NO_______


 


(i)           For all Subscribers, are you familiar with the risk aspects and the non-liquidity of investments such as the securities for which you seek to subscribe?


 


YES_______                                           NO_______


 


(j)            For all Subscribers, do you understand that there is no guarantee of financial return on this investment and that you run the risk of losing your entire investment?


 


YES_______                                           NO_______


 


6.3   MANNER IN WHICH TITLE IS TO BE HELD.  (circle one)


 


(a)           Individual Ownership


(b)           Community Property


(c)           Joint Tenant with Right of


Survivorship (both parties


must sign)


(d)           Partnership*


(e)           Tenants in Common


 




  





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              (f)           Company*


(g)           Trust*


(h)           Other*


*If Securities are being subscribed for by an entity, the attached Certificate of Signatory must also be completed.


 


6.4   FINRA AFFILIATION.


 


Are you affiliated or associated with a FINRA member firm (please check one):


Yes _________                                           No __________


If Yes, please describe:


__________________________________________________________________________________________________________


__________________________________________________________________________________________________________


__________________________________________________________________________________________________________







*If Subscriber is a Registered Representative with an FINRA member firm, have the following acknowledgment signed by the appropriate party:


 


The undersigned FINRA member firm acknowledges receipt of the notice required by Article 3, Sections 28(a) and (b) of the Rules of Fair Practice.


 


_________________________________


Name of FINRA Member Firm







By: ______________________________


Authorized Officer







Date: ____________________________







6.5   The undersigned is informed of the significance to the Company of the foregoing representations and answers contained in the Confidential Investor Questionnaire contained in this Article VI and such answers have been provided under the assumption that the Company will rely on them.


 


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DOLLAR SUBSCRIPTION __________ / $3.00 = ______________ NUMBER OF UNITS







(rounded up to the nearest whole Unit)


(Minimum Subscription $24,000/8,000 Units)












 



	 	 	 	 
	Signature 	 	 Signature (if purchasing jointly)	 
	 	 	 	 
	Name Typed or Printed	 	Name Typed or Printed	 
	 	 	 	 
	Title (if Subscriber is an Entity)	 	Title (if Subscriber is an Entity)	 
	 	 	 	 
	Entity Name (if applicable)	 	Entity Name (if applicable	 
	 	 	 	 
	Address 	 	Address	 
	 	 	 	 
	City, State and Zip Code	 	City, State and Zip Code	 
	 	 	 	 
	Telephone-Business	 	Telephone-Business	 
	 	 	 	 
	Telephone-Residence 	 	Telephone-Residence	 
	 	 	 	 
	Facsimile-Business	 	Facsimile-Business	 
	 	 	 	 
	Facsimile-Residence	 	Facsimile-Residence	 
	 	 	 	 
	Tax ID # or Social Security #	 	Tax ID # or Social Security #	 
	 	 	 	 
	Name in which securities should be issued:  	 	 	 





       


Dated:                       ,2012







This Subscription Agreement is agreed to and accepted as of ________________, 2012.


 


GREEN POLKADOT BOX, INC.









By:____________________________________


Name:  Rod A. Smith


Title:           Chief Executive Officer






  





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CERTIFICATE OF SIGNATORY







(To be completed if Units are


being subscribed for by an entity)












I, ____________________________, am the ____________________________ of __________________________________________ (the “Entity”).







I certify that I am empowered and duly authorized by the Entity to execute and carry out the terms of the Subscription Agreement and to purchase and hold the Units, and certify further that the Subscription Agreement has been duly and validly executed on behalf of the Entity and constitutes a legal and binding obligation of the Entity.







IN WITNESS WHEREOF, I have set my hand this ________ day of _________________, 2012







_______________________________________


(Signature)






  





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