exv4w6










Form of Subscription Agreement

SUBSCRIPTION AGREEMENT

(For Institutional Investors only)








June __, 2008




Gentlemen:




     The undersigned (the “Investor”) hereby confirms its agreement with you as follows:



     1. This Subscription Agreement (this “Agreement”) is made as of the date set forth below
between Polymedix, Inc., a Delaware corporation (the “Company”), and the Investor.



     2. The Company has authorized the sale and issuance to certain investors of up to an aggregate
of ___million units (the “Units”), each consisting of (i) one share (each a “Share” and
collectively, the “Shares”) of its common stock, par value $0.001 per share (the “Common Stock”),
and (ii) Series A warrants (“Warrant,” collectively, the “Warrants”) to purchase one share of
Common Stock (and the fractional amount being the “Warrant Ratio”), subject to adjustment by the
Company’s Board of Directors, or a committee thereof, for a purchase price of $  per Unit (the
“Purchase Price”). The Warrants will be issued in
certificate form pursuant to the Series A Warrant Agreement (the
“Warrant Agreement”) between the Company and The
American Stock Transfer & Trust Company, LLC
(“AST”) and will be subject to the terms and
conditions of such certificate and the Warrant Agreement. The Shares issuable upon exercise of the Warrants are referred to herein as
“Warrant Shares” and, together with the Units, the Shares and the Warrants, are collectively
referred to herein as the “Securities.”



     3. The offering and sale of the Units (the “Offering”) is being made pursuant to (1) an
effective Registration Statement on Form S-1 (Registration No. 333-151084) (filed by the Company
with the Securities and Exchange Commission (the “Commission”)) (the “Registration Statement”), (2)
if applicable, certain “free writing prospectuses”(as that term is defined in Rule 405 under the
Securities Act of 1933, as amended), that have or will be filed with the Commission and delivered
to the Investor on or prior to the date hereof, (3) a preliminary prospectus dated May 21, 2008
(the “Preliminary Prospectus”), and (4) a final prospectus (together with the Preliminary
Prospectus, the “Prospectus”) containing certain supplemental information regarding the Units and
terms of the Offering that will be filed with the Commission and delivered to the Investor (or made
available to the Investor by the filing by the Company of an electronic version thereof with the
Commission) along with the Company’s counterpart to this Agreement.



     4. The Company and the Investor agree that the Investor will purchase from the Company and the
Company will issue and sell to the Investor the Units set forth below for the aggregate purchase
price set forth below. The Units shall be purchased pursuant to the Terms and Conditions for
Purchase of Units attached hereto as Annex I and incorporated herein by this reference as if fully
set forth herein. The Investor acknowledges that the Offering is not being underwritten by the
co-placement agents (the “Placement Agents”) named in the Prospectus Supplement and that there is
no minimum offering amount.



     5. The manner of settlement of the Shares included in the Units purchased by the Investor
shall be determined by such Investor as follows:



 









 






Delivery by electronic book-entry at The Depository Trust Company (“DTC”), registered in the
Investor’s name and address as set forth below, and released by The American Stock Transfer
& Trust Company, the Company’s transfer agent (the “Transfer Agent”) (attention:
                     (___) ___-___), to the Investor at the Closing (as defined in Section 3.1 of
Annex A hereto). NO LATER THAN TWO (2) BUSINESS DAYS AFTER THE EXECUTION OF THIS AGREEMENT
BY THE INVESTOR AND THE COMPANY, THE INVESTOR SHALL:




	 	(I)	 	DIRECT THE BROKER-DEALER AT WHICH THE ACCOUNT OR ACCOUNTS TO BE CREDITED WITH
THE SHARES ARE MAINTAINED TO SET UP A DEPOSIT/WITHDRAWAL AT CUSTODIAN (“DWAC”)
INSTRUCTING THE TRANSFER AGENT TO CREDIT SUCH ACCOUNT OR ACCOUNTS WITH THE SHARES, AND
	 
	 	(II)	 	REMIT BY WIRE TRANSFER THE AMOUNT OF FUNDS EQUAL TO THE AGGREGATE PURCHASE
PRICE FOR THE UNITS BEING PURCHASED BY THE INVESTOR TO THE FOLLOWING ESCROW ACCOUNT:
	 
	 	 	 	[AST&T bank wire info here.]




IT IS THE INVESTOR’S RESPONSIBILITY TO (A) MAKE THE NECESSARY WIRE TRANSFER OR CONFIRM THE PROPER
ACCOUNT BALANCE IN A TIMELY MANNER AND (B) ARRANGE FOR SETTLEMENT BY WAY OF DWAC IN A TIMELY
MANNER. IF THE INVESTOR DOES NOT DELIVER THE AGGREGATE PURCHASE PRICE FOR THE UNITS OR DOES NOT
MAKE PROPER ARRANGEMENTS FOR SETTLEMENT IN A TIMELY MANNER, THE UNITS MAY NOT BE DELIVERED AT
CLOSING TO THE INVESTOR OR THE INVESTOR MAY BE EXCLUDED FROM THE CLOSING ALTOGETHER.




     6. The Warrant shall be delivered in accordance with the terms set forth in Annex I
hereto.




     7. The Investor represents that, except as set forth below, (a) it has had no position, office
or other material relationship within the past three years with the Company or persons known to it
to be affiliates of the Company, (b) it is not a NASD member or an Associated Person (as such term
is defined under the NASD Membership and Registration Rules Section 1011) as of the Closing, and
(c) neither the Investor nor any group of Investors (as identified in a public filing made with the
Commission) of which the Investor is a part in connection with the Offering of the Units, acquired,
or obtained the right to acquire, 20% or more of the Common Stock (or securities convertible into
or exercisable for Common Stock) or the voting power of the Company on a post-transaction basis.
Exceptions: (If no exceptions, write “none.” If left blank, response will be deemed to be
“none.”)                          .



     8. The Investor represents that it has received or can obtain on the SEC’s Edgar filing system
the Prospectus, which is part of the Company’s Registration Statement, the Preliminary Prospectus,
the documents incorporated by reference therein, and any free writing



2









 




prospectus (collectively, the “Disclosure Package”), prior to or in connection with the
receipt of this Agreement along with the Company’s counterpart to this Agreement.




     9. No offer by the Investor to buy Units will be accepted and no part of the Purchase Price
will be delivered to the Company until the Company has accepted such offer by countersigning a copy
of this Agreement, and any such offer may be withdrawn or revoked, without obligation or commitment
of any kind, at any time prior to the Company (or a Placement Agent on behalf of the Company)
sending (in writing, facsimile or by electronic mail) notice of its acceptance of such offer. An
indication of interest will involve no obligation or commitment of any kind until this Agreement is
accepted and countersigned by or on behalf of the Company.



     Number of Units:



     Purchase Price Per Unit: $



     Aggregate Purchase Price: $



3









 





PYMX Signature Page




     Please confirm that the foregoing correctly sets forth the agreement between us by signing in
the space provided below for that purpose.



	 	 	 	 	 	 	 
	 	 	Dated as of: _____ __, 2008	 	 
	 
	 
	 	 	 	 	 	 
	 	 	 	 	 
	 	 	INVESTOR	 	 
	 
	 	 	 	 	 	 
	 

	 	By:	 	 	 	 
	 

	 	 	 	 

	 	 
	 
	 	 	 	 	 	 
	 

	 	Print Name:	 	 	 	 
	 

	 	 	 	 

	 	 
	 
	 	 	 	 	 	 
	 

	 	Title:	 	 	 	 
	 

	 	 	 	 

	 	 
	 
	 	 	 	 	 	 
	 

	 	Address:	 	 	 	 
	 

	 	 	 	 

	 	 
	 
	 	 	 	 	 	 
	 

	 	 	 	 

	 	 





Agreed and Accepted this ___day of                     , 2008:




POLYMEDIX, INC.




	 	 	 	 	 
	By:
	 	 	 	 
	 

	 	 

Title:
	 	 






4









 





ANNEX I




TERMS AND CONDITIONS FOR PURCHASE OF UNITS




     1. Authorization and Sale of the Units; Defined Terms.



          1.1 Subject to the terms and conditions of this Agreement, the Company has authorized the sale
of the Units.




          1.2 Capitalized terms used herein but not otherwise defined have the meanings ascribed to them
in the Agreement.




     2. Agreement to Sell and Purchase the Units; Placement Agent.



          2.1 At the Closing (as defined in Section 3.1), the Company will sell to the Investor, and the
Investor will purchase from the Company, upon the terms and conditions set forth herein, the number
of Units set forth on the last page of the Agreement to which these Terms and Conditions for
Purchase of Units are attached as Annex I (the “Signature Page”) for the aggregate purchase price
therefor set forth on the Signature Page.




          2.2 The Company proposes to enter into substantially this same form of Subscription Agreement
with certain other investors (the “Other Investors”) and expects to complete sales of Units to
them. The Investor and the Other Investors are hereinafter sometimes collectively referred to as
the “Investors,” and this Agreement and the Subscription Agreements executed by the Other Investors
are hereinafter sometimes collectively referred to as the “Agreements.”




          2.3 Investor acknowledges that the Company intends to pay Carter Securities, LLC and Fordham
Financial Management, Inc. (the “Co-Placement Agents”) a fee (the “Placement Fee”) in respect of
the sale of Units to the Investor.




          2.4
The Company has entered into an Amended and Restated Co-Placement
Agency Agreement, dated June 27, 2008 (the
“Placement Agreement”), with the Placement Agents that contains certain representations,
warranties, covenants, and agreements of the Company that may be relied upon by the Investor, which
shall be a third party beneficiary thereof. A copy of the Placement Agreement is publicly
available as Exhibit 10.21 to the Registration Statement.




          2.5 Delivery of Shares Upon Exercise of Warrants; Buy-In. Upon exercise of the Warrants, Warrant
Shares purchased under a Warrant shall be transmitted by the Transfer Agent to the holder thereof
(a “Holder”) by crediting the account of the Holder’s prime broker with the Depository Trust
Company through its Deposits and Withdrawal at Custodian (DWAC) system if the Company is a
participant in such system, and otherwise by physical delivery to the address specified by the
Holder in the Notice of Exercise (as defined in the Warrant Agreement) within three business days
from the delivery to the Transfer Agent of the Notice of Exercise, surrender of the Warrant
Certificate and payment of the aggregate exercise price thereof. If by the close of the seventh
Trading Day after delivery of a Notice of Exercise, the Transfer Agent fails to deliver to the
Holder a certificate representing the required number of Warrant Shares in the manner required
above (or make such Warrant Shares available to such Holder’s Broker), and such failure to deliver
the Warrant Shares is caused by the Company’s failure to use commercially reasonable efforts to
comply with the covenants in Section 5 of the Warrant Agreement, and if after such seventh
Trading Day and prior to the receipt of such Warrant Shares, the Holder purchases (in an open
market transaction or otherwise) shares of Common Stock to deliver in satisfaction of a sale by the
Holder of the Warrant Shares which the Holder anticipated receiving upon such exercise (a
“Buy-In”), then the Company shall, within seven Trading Days after the Holder’s request and in the
Holder’s sole discretion, either (1) pay in cash to the Holder an amount equal to the Holder’s
total purchase price (including brokerage commissions, if any) for the shares of Common Stock so
purchased (the “Buy-In Price”), at which point the Company’s obligation to deliver such certificate
through the Transfer Agent (and to issue such Warrant Shares) shall terminate or (ii) promptly
honor its obligation to deliver to the Holder a certificate or certificates representing such
Warrant Shares and pay cash to the Holder in an amount equal to the excess (if any) of the Buy-In
Price over the product of (a) such number of Warrant Shares, times (b) the closing bid price on the
date of the event giving rise to the Company’s obligation to deliver such certificate.



          2.6 Holder Restrictions on Exercise of Warrants. A Holder shall not have the right to exercise any
portion of the Warrants, pursuant to Section 2 of the Warrant Agreement or otherwise, to
the extent that after giving effect to such issuance after exercise, such Holder (together with
such Holder’s affiliates), as set forth on the applicable Notice of Exercise, would beneficially
own in excess of 4.99% of the number of shares of the Common Stock outstanding immediately after
giving effect to such issuance. For purposes of the foregoing sentence, the number of shares of
Common Stock beneficially owned by such Holder and its affiliates shall include the number of
shares of Common Stock issuable upon exercise of its Warrants with respect to which the
determination of such sentence is being made, but shall exclude the number of shares of Common
Stock which would be issuable upon (a) exercise of the remaining, non-exercised portion of the
Warrants beneficially owned by such Holder or any of its affiliates and (b) exercise or conversion
of the unexercised or non-converted portion of any other securities of the Company (including,
without limitation, any other shares of Common Stock or Warrants) subject to a limitation on
conversion or exercise analogous to the limitation contained herein beneficially owned by such
Holder or any of its affiliates. Except as set forth in the preceding sentence, for purposes of
this Section 2.6, beneficial ownership shall be calculated in accordance with Section 13(d)
of the Exchange Act, it being acknowledged
by a Holder that the Company is not representing to such Holder that such calculation is in
compliance with Section 13(d) of the Exchange Act and such Holder is solely responsible for any
schedules required to be filed in accordance therewith. To the extent that the limitation
contained in this Section 2.6 applies, the determination of whether the Warrant is
exercisable (in relation to other securities owned by such Holder) and of which a portion of the
Warrant is exercisable shall be in the sole discretion of a Holder, and the submission of a Notice
of Exercise shall be deemed to be each Holder’s determination of whether the Warrant is exercisable
(in relation to other securities owned by such Holder) and of which portion of the Warrant is
exercisable, in each case subject to such aggregate percentage limitation, and the Company shall
have no obligation to verify or confirm the accuracy of such determination. For purposes of this
Section 2.6, in determining the number of outstanding shares of Common Stock, a Holder may
rely on the number of outstanding shares of Common Stock as reflected in (x) the Company’s most
recent Form 10-Q or Form 10-K, as the case may be, (y) a more recent public announcement by the
Company or (z) any other notice by the Company or the Company’s Transfer Agent setting forth the
number of shares of Common Stock outstanding. Upon the written or oral request of a Holder, the
Company shall within two Trading Days confirm orally and in writing to such Holder the number of
shares of Common Stock then outstanding. In any case, the number of outstanding shares of Common
Stock shall be determined after giving effect to the conversion or exercise of securities of the
Company, including the Warrant, by such Holder or its affiliates since the date as of which such
number of outstanding shares of Common Stock was reported. The provisions of this Section
2.6 may be waived by such Holder, at the election of such Holder, upon not less than 61 days’
prior notice to the Company to allow the Holder to become the beneficial owner of not more than
9.99% of the Common Stock outstanding, and the provisions of this Section 2.6 shall
continue to apply until such 61st day (or such later date, as determined by such Holder, as may be
specified in such notice of waiver).




     3. Closings and Delivery of the Units and Funds.



          3.1 Closing. The completion of the purchase and sale of the Units (the “Closings”) shall
occur at one or more places and times (the “Closing Dates”) to be specified by the Company and the
Placement Agent, and of which the Investors will be notified in advance by the Placement Agents, in
accordance with Rule 15c6-1 promulgated under the Exchange Act. At each Closing, (a) the Company shall cause the Transfer Agent to deliver to the
Investor the number of Shares set forth on the Signature Page registered in the name of the
Investor or, if so indicated on the Investor Questionnaire attached hereto as Schedule A, in the
name of a nominee designated by the




 









 




Investor and as contemplated by procedures set forth in the Agreement and the Placement
Agreement, (b) the Company shall cause to be delivered to the
Investor a Warrant in certificate form through AST, as the
Company’s transfer agent, to purchase a
number of whole Warrant Shares determined by multiplying the number of Shares set forth on the
signature page by the Warrant Ratio and rounding down to the nearest whole number and (c) the
aggregate purchase price for the Units being purchased by the Investor will be delivered by
AST, as Escrow Agent, on behalf of the Investor to the
Company.




          3.2 (a) Conditions to the Company’s Obligations. The Company’s obligation to issue and sell
the Units to the Investor shall be subject to: (i) the receipt by the Company of the purchase price
for the Units being purchased hereunder as set forth on the Signature Page and (ii) the accuracy of
the representations and warranties made by the Investor and the fulfillment of those undertakings
of the Investor to be fulfilled prior to the Closing Date.




               (b) Conditions to the Investor’s Obligations. The Investor’s obligation to purchase the Units
will be subject to the accuracy of the representations and warranties made by the Company contained
in the Placement Agreement and the fulfillment of those undertakings of the Company to be fulfilled
prior to the Closing Date those contained in the Placement Agreement and the Subscription
Agreement, and to the condition that the Placement Agents shall not have determined that the
conditions to the closing in the Placement Agreement have not been satisfied. The Investor’s
obligations are expressly not conditioned on the purchase by any or all of the Other Investors of
the Units that they have agreed to purchase from the Company or the issuance of any minimum amount
of Units by the Company.



          3.3 Delivery of Funds. No later than two (2) business days after the execution of this
Agreement by the Investor and the Company, the Investor shall remit by wire transfer the amount
of funds equal to the aggregate purchase price for the Units being purchased by the Investor to the
following account designated by the Escrow Agent:




     [AST wire instructions here]



          3.4 Delivery of Shares by Electronic Book-Entry at The Depository Trust Company. No later
than two (2) business days after the execution of this Agreement by the Investor and the
Company, the Investor shall direct the broker-dealer at which the account or accounts to be
credited with the Shares being purchased by such Investor are maintained, which broker/dealer shall
be a DTC participant, to set up a Deposit/Withdrawal at Custodian
(“DWAC”) instructing AST, as the Company’s transfer agent, to credit such account or accounts
with the Shares by means of an electronic book-entry delivery. Such DWAC shall indicate the
settlement date for the deposit of the Shares, which date shall be provided to the Investor by the
Placement Agents. Simultaneously with the delivery to the Company by the Investor of the funds
pursuant to Section 3.3 above, the Company shall direct its transfer agent to credit the Investor’s
account or accounts with the Shares pursuant to the information contained in the DWAC.




 









 








     4. Representations, Warranties and Covenants of the Investor.



          4.1 The Investor represents and warrants to, and covenants with, the Company that (a) the
Investor has answered all questions on the Signature Page and the Investor Questionnaire for use in
preparation of the Prospectus Supplement and the answers thereto are true and correct as of the
date hereof and will be true and correct as of the Closing Date and (b) the Investor, in connection
with its decision to purchase the number of Units set forth on the Signature Page, is relying only
upon the Disclosure Package and the representations and warranties of the Company contained herein
and the Co-Placement Agency Agreement.




          4.2 The Investor acknowledges, represents and agrees that no action has been or will be taken
in any jurisdiction outside the United States by the Company or either Placement Agent that would
permit an offering of the Units, or possession or distribution of offering materials in connection
with the issue of the Units in any jurisdiction outside the United States where action for that
purpose is required. Each Investor outside the United States will comply with all applicable laws
and regulations in each foreign jurisdiction in which it purchases, offers, sells or delivers Units
or has in its possession or distributes any offering material, in all cases at its own expense.
The Placement Agents are not authorized to make and have not made any representation or use of any
information in connection with the issue, placement, purchase and sale of the Units, except as set
forth or incorporated by reference in the Disclosure Package.




          4.3 The Investor further represents and warrants to, and covenants with, the Company that (a)
the Investor has full right, power, authority and capacity to enter into this Agreement and to
consummate the transactions contemplated hereby and has taken all necessary action to authorize the
execution, delivery and performance of this Agreement, and (b) this Agreement constitutes a valid
and binding obligation of the Investor enforceable against the Investor in accordance with its
terms, except as enforceability may be limited by applicable bankruptcy, insolvency,
reorganization, moratorium or similar laws affecting creditors’ and contracting parties’ rights
generally and except as enforceability may be subject to general principles of equity (regardless
of whether such enforceability is considered in a proceeding in equity or at law) and except as the
indemnification agreements of the Investors herein may be legally unenforceable.




          4.4 The Investor understands that nothing in this Agreement, the Prospectus or any other
materials presented to the Investor in connection with the purchase and sale of the Units
constitutes legal, tax or investment advice. The Investor has consulted such legal, tax and
investment advisors as it, in its sole discretion, has deemed necessary or appropriate in
connection with its purchase of Units.




          4.5 Each Investor represents, warrants and agrees that, since the earlier to occur of (i) the
date on which a Placement Agent first contacted such Investor about the Offering and (ii) the date
of this Agreement, it has not engaged in any transactions in the securities of the Company
(including, without limitation, any Short Sales involving the Company’s securities). Each Investor
covenants that it will not engage in any transactions in the securities of the Company (including
Short Sales) prior to the time that the transactions contemplated by this Agreement have been
consummated and are publicly disclosed. Each Investor agrees that it will not use any of the Units
acquired pursuant to this Agreement to cover any short position in the




 









 




Common Stock if doing so would be in violation of applicable securities laws. For purposes
hereof, “Short Sales” include, without limitation, all “short sales” as defined in Rule 200
promulgated under Regulation SHO under the Exchange Act, whether or not against the box, and all
types of direct and indirect stock pledges, forward sales contracts, options, puts, calls, short
sales, swaps, “put equivalent positions” (as defined in Rule 16a-1(h) under the Exchange Act) and
similar arrangements (including on a total return basis), and sales and other transactions through
non-US broker dealers or foreign regulated brokers.




     5. Survival of Representations, Warranties and Agreements; Third Party Beneficiary.
Notwithstanding any investigation made by any party to this Agreement or by the Placement Agent,
all covenants, agreements, representations and warranties made by the Company and the Investor
herein will survive the execution of this Agreement, the delivery to the Investor of the Units
being purchased and the payment therefor. The Placement Agents shall each be a third party
beneficiary with respect to representations, warranties and agreements of the Investor in Section 4
hereof.



     6. Notices. All notices, requests, consents and other communications hereunder will be in
writing, will be mailed (a) if within the domestic United States by first-class registered or
certified airmail, or nationally recognized overnight express courier, postage prepaid, or by
facsimile or (b) if delivered from outside the United States, by International Federal Express or
facsimile, and will be deemed given (i) if delivered by first-class registered or certified mail
domestic, three business days after so mailed, (ii) if delivered by nationally recognized overnight
carrier, one business day after so mailed, (iii) if delivered by International Federal Express, two
business days after so mailed and (iv) if delivered by facsimile, upon electric confirmation of
receipt and will be delivered and addressed as follows:



               (a) if to the Company, to:


Polymedix, Inc.

170 N. Radnor-Chester Road

Suite 300

Radnor, Pennsylvania 19087

Facsimile: (484) 598-2333

Attention: Edward F. Smith, Chief Financial Officer



with copies to:



Pepper Hamilton, LLP

400 Berwyn Park

899 Cassatt Avenue

Berwyn, Pennsylvania 19312

Attention: Jeffrey P. Libson

Facsimile: (610) 640-7835




               (b) if to the Investor, at its address on the Signature Page hereto, or at such other address
or addresses as may have been furnished to the Company in writing.



 









 





     7. Changes. This Agreement may not be modified or amended except pursuant to an instrument in
writing signed by the Company and the Investor.



     8. Headings. The headings of the various sections of this Agreement have been inserted for
convenience of reference only and will not be deemed to be part of this Agreement.



     9. Severability. In case any provision contained in this Agreement should be invalid, illegal
or unenforceable in any respect, the validity, legality and enforceability of the remaining
provisions contained herein will not in any way be affected or impaired thereby.



     10. Governing Law. This Agreement will be governed by, and construed in accordance with, the
internal laws of the State of New York, without giving effect to the principles of conflicts of law
that would require the application of the laws of any other jurisdiction.



     11. Counterparts. This Agreement may be executed in two or more counterparts, each of which
will constitute an original, but all of which, when taken together, will constitute but one
instrument, and will become effective when one or more counterparts have been signed by each party
hereto and delivered to the other parties. The Company and the Investor acknowledge and agree that
the Company shall deliver its counterpart to the Investor along with the Prospectus and the
Prospectus Supplement (or the filing by the Company of an electronic version thereof with the
Commission).



     12. Confirmation of Sale. The Investor acknowledges and agrees that such Investor’s receipt
of the Company’s counterpart to this Agreement, together with the Prospectus and the Prospectus
Supplement (or the filing by the Company of an electronic version thereof with the Commission),
shall constitute written confirmation of the Company’s sale of Units to such Investor.



     13. Termination. In the event that the Company decides to terminate Offering prior to
Closing, this Agreement shall terminate without any further action on the part of the parties
hereto and any monies remitted to the Escrow Agent will be promptly refunded by the Escrow Agent,
without interest, to the Investor.



 









 






SCHEDULE A TO ANNEX I

POLYMEDIX, INC.

INVESTOR QUESTIONNAIRE




     Pursuant to Section 3 of Annex I to the Agreement, please provide us with the following
information:




	 	1.	 	The exact name that your Shares and Warrants are to be registered in. You may
use a nominee name if appropriate:
	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	2.	 	The relationship between the Investor and the registered holder listed in
response to item 1 above:
	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	3.	 	The mailing address of the registered holder listed in response to item 1
above:
	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	4.	 	The Social Security Number or Tax Identification Number of the registered
holder listed in the response to item 1 above:
	 
	 	 	 	 

	 
	 	5.	 	Name of DTC Participant (broker-dealer at which the account or accounts to be
credited with the Shares are maintained); please include the name and telephone number
of the contract person at the broker-dealer:
	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	 	 	 






Schedule A to Annex I- Page 1




 









 







	 	6.	 	DTC Participant Number:
	 
	 	 	 	 

	 
	 	7.	 	Name of Account at DTC Participant being credited with the Shares:
	 
	 	 	 	 

	 
	 	 	 	 

	 
	 	8.	 	Account Number at DTC Participant being credited with the Shares:
	 
	 	 	 	 






Schedule A to Annex I- Page 2