Form of Subscription Agreement



 Exhibit 10.1 
 SUBSCRIPTION AGREEMENT 
 Jazz Pharmaceuticals, Inc. 
 3180 Porter Drive 
 Palo Alto, CA 94304 
 Ladies and Gentlemen: 
 The undersigned (the “Investor”) hereby confirms its agreement with you as follows: 
 1. This Subscription Agreement, including the Terms and Conditions For Purchase of Units attached hereto as Annex I (collectively, this
“Agreement”) is made as of the date set forth below between Jazz Pharmaceuticals, 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 3,848,289 units (the “Units”),
with each Unit consisting of (i) one share (the “Share,” collectively, the “Shares”) of its common stock, par value $0.0001 per share (the “Common Stock”), and (ii) one warrant (the
“Warrant,” collectively, the “Warrants”) to purchase 0.45 of a share of Common Stock (and the fractional amount being the “Warrant Ratio”), in substantially the form attached hereto as Exhibit
B, subject to adjustment by the Company’s Board of Directors, or a committee thereof, for a purchase price of $6.75625 per Unit (the “Purchase Price”). Units will not be issued or certificated. The Shares and Warrants are
immediately separable and will be issued separately. The shares of Common Stock issuable upon exercise of the Warrants are referred to herein as the “Warrant Shares” and, together with the Units, the Shares and the Warrants, are
referred to herein as the “Securities”). 
 3. The offering and sale of the Units (the “Offering”)
are being made pursuant to (1) an effective Registration Statement on Form S-3 (File No. 333-151593) (including the Prospectus contained therein (the “Base Prospectus”), the “Registration Statement”) filed
by the Company with the Securities and Exchange Commission (the “Commission”), (2) the “free writing prospectus” (as that term is defined in Rule 405 under the Securities Act of 1933, as amended (the
“Act”)), dated July 15, 2008 (the “Issuer Free Writing Prospectus”), containing certain supplemental information regarding the Securities, the terms of the Offering and information that may be material to the
Company and its securities that has been or will be filed with the Commission, and that has been delivered to the Investor on or prior to the date hereof, and (3) a Prospectus Supplement (the “Prospectus Supplement” and
together with the Base Prospectus, the “Prospectus”) containing certain supplemental information regarding the Securities, the terms of the Offering the terms of the Offering and information that may be material to the Company and
its securities 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). 
 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 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 (check one): 
  

					
	[        ]	  	A.	  	Delivery by crediting the account of the Investor’s prime broker (as specified by such Investor on Exhibit A annexed
hereto) with the Depository Trust Company
(“DTC”) through its Deposit/Withdrawal At Custodian (“DWAC”) system,
whereby Investor’s prime broker shall initiate a DWAC transaction on the Closing Date using its DTC participant
identification number,
and released by Computershare Trust Company, N.A., the Company’s transfer agent (the “Transfer
Agent”), at the Company’s direction. NO LATER THAN ONE (1) BUSINESS DAY 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 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 ACCOUNT:


 JPMorgan Chase Bank, N.A. 
 ABA # 021000021 
 Account Name: Jazz
Pharmaceuticals, Inc. 
 Account Number: 77132705 
 Attention: Audrey Cohen 
 Tel: (212) 623-5078 
  

					
		  	– OR –
			
	[        ]	  	B.	  	Delivery versus payment (“DVP”) through DTC (i.e., the Company shall deliver Shares registered in the Investor’s name
and address as set forth below and released
by the Transfer Agent to the Investor through DTC at the Closing directly to
the account(s) at Lazard Capital Markets LLC (“LCM”) identified by the Investor and simultaneously therewith payment
shall be made by LCM by wire
transfer to the Company). NO LATER THAN ONE (1) BUSINESS DAY AFTER THE
EXECUTION OF THIS AGREEMENT BY THE INVESTOR AND THE COMPANY, THE INVESTOR SHALL:
			
		  		  	 (I)     NOTIFY LCM OF THE ACCOUNT OR ACCOUNTS AT LCM TO BE CREDITED WITH THE SHARES BEING PURCHASED BY SUCH
INVESTOR, AND

			
		  		  	 (II)    CONFIRM THAT THE ACCOUNT OR ACCOUNTS AT LCM TO BE CREDITED WITH THE SHARES
BEING PURCHASED BY THE INVESTOR HAVE A MINIMUM BALANCE EQUAL TO THE AGGREGATE PURCHASE PRICE FOR THE UNITS BEING PURCHASED BY THE INVESTOR.


  

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 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 OR DVP 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 OFFERING ALTOGETHER. 
 6. The executed Warrant included in the Units purchased by the Investor shall be delivered in accordance with the terms thereof. 
 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 FINRA member or an Associated Person (as such term is defined under the FINRA 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, 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 otherwise had made available
to it by the filing by the Company of an electronic version thereof with the Commission) the Base Prospectus, dated June 19, 2008, which is a part of the Company’s Registration Statement, the documents incorporated by reference therein and
the Issuer Free Writing Prospectus (collectively, the “Disclosure Package”), which includes pricing and other information regarding the Offering (the “Offering Information”), prior to or in connection with the
receipt of this Agreement. The Investor acknowledges that the Issuer Free Writing Prospectus included in the Disclosure Package contains information that may be material to the Company and its securities that will not be disclosed to the public
until the Company files a Current Report on Form 8-K in accordance with Section 13 of Annex I hereto, and the Investor agrees not to transact or agree to transact in the Company’s securities or otherwise use such information unless and
until (a) the Company files with the SEC on July 16, 2008 a Current Report on Form 8-K in accordance with Section 13 of Annex I hereto and (b) The NASDAQ Global Market has opened for regular trading on July 16, 2008.

 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 Investor has received the Disclosure Package including the Offering Information and 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 (orally, in writing 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 the Investor has been delivered the Disclosure Package including the Offering Information and this Agreement is accepted and countersigned by or on behalf of the Company. 
  

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 Number of
Units:                                        
                                         

 Purchase Price Per Unit:
$                                         
                         
 Aggregate Purchase Price:
$                                         
                       
 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: July [__], 2008
	
	 
	INVESTOR
		
	By:	 	 
	Print Name:	 	 
	Title:	 	 
	Address:	 	 
	
	 


 Agreed and Accepted 
 this [            ] day of July, 2008: 
  

			
	JAZZ PHARMACEUTICALS, INC.
		
	By:	 	 
	Title:	 	

  

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 ANNEX I 
 TERMS AND CONDITIONS FOR PURCHASE OF UNITS 
 1. Authorization and Sale of the Units. Subject
to the terms and conditions of this Agreement, the Company has authorized the sale of the Units. 
 2. Agreement to Sell and Purchase the
Units; Placement Agents. 
 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 has agreed to pay Lazard Capital Markets
LLC (“LCM”) and Leerink Swann LLC (“Leerink”, together with LCM, the “Placement Agents”) a fee (the “Placement Fee”) in respect of the sale of Units to the Investor. 
 2.4 The Company has entered into a Placement Agent Agreement, dated July 15, 2008 (the “Placement
Agreement”), with the Placement Agents that contains certain representations, warranties, covenants and agreements of the Company that, subject to Section 5 hereof, may be relied upon by the Investor, which shall be a third party
beneficiary thereof. 
 3. Closings and Delivery of the Units and Funds. 
 3.1 Closing. The completion of the purchase and sale of the Units (the “Closing”) shall occur at a place
and time (the “Closing Date”) to be specified by the Company and LCM, and of which the Investors will be notified in advance by LCM, in accordance with Rule 15c6-1 promulgated under the Securities Exchange Act of 1934, as amended
(the “Exchange Act”). At the 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 Exhibit A, in the name of a nominee designated by the Investor, (b) the Company shall cause to be delivered to the Investor a Warrant 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 or on
behalf of the Investor to the Company. 
 3.2 Conditions to the Company’s Obligations. (a) 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. 
  


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 (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 and the fulfillment of those undertakings of the Company to be fulfilled prior to the Closing Date, including without
limitation, those contained in the Placement Agreement, and to the condition that the Placement Agents shall not have: (a) terminated the Placement Agreement pursuant to the terms thereof or (b) 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.

 3.3 Delivery of Funds. 
 (a) DWAC Delivery. If the Investor elects to settle the Shares included in the Units purchased by such Investor through DTC’s Deposit/Withdrawal at Custodian (“DWAC”) delivery system,
no later than one (1) business day 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 Company and the Placement Agents pursuant to the terms of that certain Escrow Agreement (the “Escrow Agreement”) dated as of the date hereof, by and among the
Company, the Placement Agents and JPMorgan Chase Bank, N.A. (the “Escrow Agent”): 
 JPMorgan Chase Bank, N.A. 

ABA # 021000021 
 Account Name: Jazz
Pharmaceuticals, Inc. 
 Account Number: 77132705 
 Attention: Audrey Cohen 
 Such funds shall be held in escrow until the Closing and
delivered by the Escrow Agent on behalf of the Investors to the Company upon the satisfaction, in the sole judgment of LCM, of the conditions set forth in Section 3.2(b) hereof. The Placement Agents shall have no rights in or to any of the
escrowed funds, unless the Placement Agents and the Escrow Agent are notified in writing by the Company in connection with the Closing that a portion of the escrowed funds shall be applied to the Placement Fee. The Company and the Investor agree to
indemnify and hold the Escrow Agent harmless from and against any and all losses, costs, damages, expenses and claims (including, without limitation, court costs and reasonable attorneys fees) (“Losses”) arising under this
Section 3.3 or otherwise with respect to the funds held in escrow pursuant hereto or arising under the Escrow Agreement, unless it is finally determined that such Losses resulted directly from the willful misconduct or gross negligence of the
Escrow Agent. Anything in this Agreement to the contrary notwithstanding, in no event shall the Escrow Agent be liable for any special, indirect or consequential loss or damage of any kind whatsoever (including but not limited to lost profits), even
if the Escrow Agent has been advised of the likelihood of such loss or damage and regardless of the form of action. 
 (b)
Delivery Versus Payment through The Depository Trust Company. If the Investor elects to settle the Shares included in the Units purchased by such Investor by delivery versus payment through DTC, no later than one (1) business day after
the execution of this Agreement by the Investor and the Company, the Investor shall confirm that the account or accounts at LCM to be credited with the Units being purchased by the Investor have a minimum balance equal to the aggregate purchase
price for the Units being purchased by the Investor. 
  

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 3.4 Delivery of Shares. 
 (a) DWAC Delivery. If the Investor elects to settle the Shares included in the Units purchased by such Investor through DTC’s
DWAC delivery system, no later than one (1) business day 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 DWAC instructing the Transfer Agent to credit such account or accounts with the Shares. Such DWAC instruction shall indicate the
settlement date for the deposit of the Shares, which date shall be provided to the Investor by LCM. Simultaneously with the delivery to the Company by the Escrow Agent of the funds held in escrow pursuant to Section 3.3 above, the
Company shall direct the Transfer Agent to credit the Investor’s account or accounts with the Shares pursuant to the information contained in the DWAC. 
 (b) Delivery Versus Payment through The Depository Trust Company. If the Investor elects to settle the Shares included in the Units
purchased by such Investor by delivery versus payment through DTC, no later than one (1) business day after the execution of this Agreement by the Investor and the Company, the Investor shall notify LCM of the account or accounts
at LCM to be credited with the Shares being purchased by such Investor. On the Closing Date, the Company shall deliver the Shares to the Investor through DTC directly to the account(s) at LCM identified by Investor and simultaneously therewith
payment shall be made by LCM by wire transfer to the Company. 
 4. Representations, Warranties and Covenants of the Investor.

 The Investor acknowledges, represents and warrants to, and agrees with, the Company and the Placement Agents that: 
 4.1 The Investor (a) is knowledgeable, sophisticated and experienced in making, and is qualified to make decisions with
respect to, investments in securities presenting an investment decision like that involved in the purchase of the Units, including investments in securities issued by the Company and investments in comparable companies, (b) has answered all
questions on the Signature Page and the Investor Questionnaire 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 (c) in connection with its decision to purchase the number
of Units set forth on the Signature Page, has received and is relying only upon the Disclosure Package (including the documents incorporated by reference therein). 
  

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 4.2(a) No action has been or will be taken in any jurisdiction outside the United
States by the Company or the Placement Agents that would permit an offering of the Units, or possession or distribution of offering materials in connection with the issue of the Securities in any jurisdiction outside the United States where action
for that purpose is required, (b) if the Investor is outside the United States, it will comply with all applicable laws and regulations in each foreign jurisdiction in which it purchases, offers, sells or delivers Securities or has in its
possession or distributes any offering material, in all cases at its own expense and (c) the Placement Agents are not authorized to make and have not made any representation, disclosure or use of any information in connection with the issue,
placement, purchase and sale of the Units, except as set forth in the Issuer Free Writing Prospectus or as set forth in or incorporated by reference in the Base Prospectus or the Prospectus Supplement. 
 4.3(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 to the enforceability of any rights to indemnification or contribution that may be violative
of the public policy underlying any law, rule or regulation (including any federal or state securities law, rule or regulation). 
 4.4 The Investor understands that nothing in this Agreement, the Prospectus, the Disclosure Package 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. The Investor also understands that there is no
established public trading market for the Warrants being offered in the Offering, and that the Company does not expect such a market to develop. In addition, the Company does not intend to apply for listing the Warrants on any securities exchange.
Without an active market, the liquidity of the Warrants will be limited. 
 4.5 Since the date on which the Placement
Agents first contacted such Investor about the Offering, the Investor has not engaged in any transactions in the securities of the Company (including, without limitation, any Short Sales involving the Company’s securities), and has not violated
its obligations of confidentiality. Each Investor covenants that it will not engage in any transactions in the securities of the Company (including Short Sales) or disclose any information about the Offering (other than to its advisors that are
under a legal obligation of confidentiality prior to the later of (a) the time that the transactions contemplated by this Agreement are publicly disclosed and (b) the open of regular trading on The NASDAQ Global Market on July 16,
2008. Each Investor agrees that it will not use any of the Securities 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. 
  

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 5. Survival of Representations, Warranties and Agreements; Third Party Beneficiary.
Notwithstanding any investigation made by any party to this Agreement or by the Placement Agents, 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 for a period of twenty-four (24) months following the delivery to the Investor of the Units. The Placement Agents and Lazard Fréres & Co. shall
be third party beneficiaries with respect to the 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: 
 Jazz Pharmaceuticals, Inc. 
 3180 Porter Drive 
 Palo Alto, CA 94304 

 Attention: Carol Gamble, General Counsel 
 Facsimile:(650) 496-3781 
 with copies to (which shall not constitute notice): 
 Cooley Godward Kronish LLP 
 Five Palo Alto
Square 
 3000 El Camino Real 
 Palo Alto, CA 94306  
 Attention: Suzanne Sawochka Hooper, Esq. 
 Facsimile: (650) 849-7400 
 (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. 
  

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 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 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 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. Press Release. The Company and the Investor agree that the Company shall issue a press release and file a Form 8-K announcing the Offering prior to the open of regular trading on The NASDAQ Global Market on
July 16, 2008, which such Form 8-K shall include any other material information regarding the Company that is contained in the Issuer Free Writing Prospectus. 
 14. Termination. In the event that the Placement Agreement is terminated by the Placement Agents pursuant to the terms thereof, this Agreement shall terminate without any further action on the part of the
parties hereto. 
  

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 EXHIBIT A 
 JAZZ PHARMACEUTICALS, 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):
	 	_________________
		
	 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:
	 	_________________








 Exhibit B 
 Form of Warrant