Exhibit
10.1


 


SUBSCRIPTION
AGREEMENT


 


This
Subscription Agreement (this “Agreement”) has been executed by the purchaser set forth on the signature page
hereof (the “Purchaser”) in connection with the private placement offering (the “Offering”)
by IR-Med, Inc, Inc., a Nevada corporation (the “Company”).


 


R
E C I T A L S


 


A.
The Company is offering to qualified accredited investors units of its securities (the “Offering”) where each
unit is comprised of (each, a “Unit” and, collectively, the “Units”) (i) one (1) shares of the
Company’s common stock, par value $0.001 per share (“Common Stock”), and (ii) a warrant to purchase an
additional share of the Company’s Common Stock, exercisable for a three year period at a per share exercise price of $1.10, subject
to adjustment, and substantially in the form of warrant attached hereto as Appendix A (the “Warrant”),
at a per Unit purchase price of $0.88 (the “Purchase Price”).


 


B.
The proceeds of the Offering will be used by the Company for, among other, the working capital purposes of its wholly-owned subsidiary,
IR-Med Ltd., a company formed under the laws of the State of Israel (“IR-Med”).


 


C.
The Securities (as defined below) subscribed for pursuant to this Agreement have not been registered under the Securities Act of 1933,
as amended (the “Securities Act”). The Offering is being made on a reasonable best efforts basis to “accredited
investors,” as defined in Regulation D under the Securities Act in reliance upon the exemption from securities registration afforded
by Section 4(a)(2) of the Securities Act and Rule 506 of Regulation D.


 


AGREEMENT


 


The
Company and the Purchaser hereby agree as follows:


 


1.
Subscription.


 


1.1
Purchase and Sale of the Securities.


 


(a)
Subject to the terms and conditions of this Agreement, the undersigned Purchaser agrees to purchase, and the Company agrees to sell and
issue to such Purchaser, that number of Units set forth on such Purchaser’s Signature Page attached hereto at the Purchase Price,
for a total aggregate Purchase Price as set forth on such Omnibus Signature Page.


 











(b)
This Agreement is one of a series of subscription agreements issued (and to be issued) by the Company to purchasers of Units in connection
with the Offering with the same terms and conditions set forth in this Agreement (each, a “Subscription Agreement”,
and collectively, the “Subscription Agreements”).


 


1.2
Subscription Procedure; Closing.


 


(a)
Closing. Subject to the terms and conditions of this Agreement, the closing of the Units shall take place remotely via the exchange
of documents and signatures or at such other time and place as fixed by the Company (as defined in Section 2) (the “Closing”).


 






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(b)
Subscription Procedure. To complete a subscription for the Units, the Purchaser must fully comply with the subscription procedure
provided in paragraphs a. through c. of this Section on or before the applicable Closing:


 


(i)
Subscription Documents. At or before the Closing, the Purchaser shall review, complete and execute the Signature Page to this
Agreement, Investor Profile, Anti-Money Laundering Form and Investor Certification, attached hereto following the Omnibus Signature Page
(collectively, the “Subscription Documents”), if applicable, additional forms and questionnaires distributed
to the Purchaser and deliver the Subscription Documents and such additional forms and questionnaires to the party indicated thereon at
the address set forth on the signature page below. Executed documents may be delivered to such party by facsimile or .pdf sent by electronic
mail (e-mail).


 


(ii)
Purchase Price. Simultaneously with the delivery of the Subscription Documents as provided herein, the Purchaser shall remit to
the Company the full Purchase Price by certified or other bank check or by wire transfer of immediately available funds. The details
of the Company’s bank account to which the Purchase Price is to be remitted are set forth on Appendix B.


 


(iii)
Company Discretion. The Purchaser understands and agrees that the Company in its sole discretion reserves the right to accept
or reject this or any other subscription for Units. The Company shall have no obligation hereunder until the Company shall execute and
deliver to the Purchaser an executed copy of this Agreement.


 


2.
Representations and Warranties of the Company. The Company hereby represents and warrants to the Purchaser, as of the Closing,
the following:


 


a.
Organization and Qualification. The Company is a corporation duly organized, validly existing and in good standing under the laws
of Nevada, and has the requisite corporate power to own its properties and to carry on its business as now being conducted. The Company
and each of its subsidiaries is duly qualified as a foreign corporation to do business and is in good standing in every jurisdiction
in which the nature of the business conducted by it makes such qualification necessary, except to the extent that the failure to be so
qualified or be in good standing would not have a material adverse effect on the assets, business, financial condition, results of operations
or future prospects of the Company and its subsidiaries taken as a whole (a “Material Adverse Effect”).


 


b.
Authorization, Enforcement, Compliance with Other Instruments. (i) The Company has the requisite corporate power and authority
to enter into and perform its obligations under this Agreement (the “Transaction Documents”) and to issue the
Units and the underlying shares of Common Stock comprising the Unit and the shares of Common Stock issuable upon exercise of the Warrant
(collectively, the “Securities”), in accordance with the terms hereof and thereof; (ii) the execution and delivery
by the Company of each of the Transaction Documents and the consummation by it of the transactions contemplated hereby and thereby, including,
without limitation, the issuance of the Securities, have been, or will be at the time of execution of such Transaction Document by the
Company, duly authorized by the Company’s Board of Directors, and no further consent or authorization is, or will be at the time
of execution of such Transaction Document, required by the Company, its Board of Directors or its stockholders; (iii) each of the Transaction
Documents will be duly executed and delivered by the Company; and (iv) the Transaction Documents when executed will constitute the valid
and binding obligations of the Company enforceable against the Company in accordance with their terms, except as such enforceability
may be limited by general principles of equity or applicable bankruptcy, insolvency, reorganization, moratorium, liquidation or similar
laws relating to, or affecting generally, the enforcement of creditors’ rights and remedies and, with respect to any rights to
indemnity or contribution contained in the Transaction Documents, as such rights may be limited by state or federal laws or public policy
underlying such laws.


 



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c.
Issuance of Securities. The Units and the underlying Securities that are being issued to the Purchaser hereunder, when issued,
sold and delivered in accordance with the terms and for the consideration set forth in this Agreement, will be duly and validly issued,
fully paid and nonassessable, and free of restrictions on transfer other than restrictions on transfer under the Transaction Documents,
applicable state and federal securities laws and liens or encumbrances created by or imposed by the Purchaser.


 


d.
No Conflicts. The execution, delivery and performance of each of the Transaction Documents by the Company, and the consummation
by the Company of the transactions contemplated hereby and thereby including issuance and sale of the Securities in accordance with this
Agreement will not (i) result in a violation of the Certificate of Incorporation or the Bylaws (or equivalent constitutive document)
of the Company or any of its subsidiaries or (ii) violate or conflict with, or result in a breach of any provision of, or constitute
a default (or an event which with notice or lapse of time or both would become a default) under, or give to others any rights of termination,
amendment, acceleration or cancellation of, any agreement, indenture or instrument to which the Company or any subsidiary is a party,
except for those which would not reasonably be expected to have, individually or in the aggregate, a Material Adverse Effect, or (iii)
result in a violation of any law, rule, regulation, order, judgment or decree (including U.S. federal and state securities laws and regulations)
applicable to the Company or any subsidiary or by which any property or asset of the Company or any subsidiary is bound or affected,
except for those which would not reasonably be expected, individually or in the aggregate, to have a Material Adverse Effect. Neither
the Company nor any subsidiary is in violation of or in default under, any provision of its Certificate of Incorporation or Bylaws. Neither
the Company nor any subsidiary is in violation or breach of any term of or in default under any contract, agreement, mortgage, indebtedness,
indenture, instrument, judgment, decree or order or any statute, rule or regulation applicable to the Company or any subsidiary, except
for any violations, breaches or defaults which would not reasonably be expected to have, individually or on the aggregate, a Material
Adverse Effect. Except as specifically contemplated by this Agreement and as required under the Securities Act and any applicable state
securities laws, neither the Company nor any of its subsidiaries is required to obtain any consent, authorization or order of, or make
any filing or registration with, any court or governmental agency in order for it to execute, deliver or perform any of its obligations
under or contemplated by this Agreement or the other Transaction Documents in accordance with the terms hereof or thereof. Neither the
execution and delivery by the Company of the Transaction Documents, nor the consummation by the Company of the transactions contemplated
hereby or thereby, will require any notice, consent or waiver under any contract or instrument to which the Company or any subsidiary
is a party or by which the Company or any subsidiary is bound or to which any of their assets is subject, except for any notices, consents
or waivers the absence of which would not reasonably be expected, individually or in the aggregate, to have a Material Adverse Effect.
All consents, authorizations, orders, filings and registrations which the Company or any of its subsidiaries is required to obtain pursuant
to the preceding two sentences have been or will be obtained or effected on or prior to the Closing.


 



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e.
Absence of Litigation. There is no action, suit, claim, inquiry, notice of violation, proceeding (including any partial proceeding
such as a deposition) or investigation before or by any court, public board, governmental or administrative agency, self-regulatory organization,
arbitrator, regulatory authority, stock market, stock exchange or trading facility (an “Action”) now pending
or, to the knowledge of the Company, threatened against or affecting the Company or any of its subsidiaries or any of their respective
officers or directors, (i) which, together with all other Actions, would be reasonably likely to adversely affect the validity or enforceability
of, or the authority or ability of the Company to perform its obligations under, this Agreement or any of the other Transaction Documents,
or (ii) which, together with all other Actions, would be reasonably likely to have a Material Adverse Effect. For the purpose of this
Agreement, the knowledge of the Company means the knowledge of the officers of the Company and IR-Med (both actual or knowledge that
they would have had upon reasonable inquiry of the personnel of IR-Med responsible for the applicable subject matter). Neither the Company
nor any of its subsidiaries is subject to any judgment, decree, or order which has had, or would reasonably be expected to have a Material
Adverse Effect.


 


f.
Use of Proceeds. The Company presently intends to use the net proceeds from the Offering to fund continuing design and development
of IR Med’s product line, regulatory approval process, production and marketing as well for working capital and other general corporate
purposes.


 


g.
All of the information concerning the Company set forth herein, and any other information furnished by the Company in writing to the
Purchaser for use in connection with the transactions contemplated by this Agreement, is true, correct and complete in all material respects
as of the date of this Agreement, and, if there should be any material change in such information prior to the Purchaser’s purchase
of the Units and Securities, the Company will promptly furnish revised or corrected information to the Purchaser.


 


3.
Representations, Warranties and Agreements of the Purchaser. The Purchaser, severally and not jointly with any other Purchaser,
represents and warrants to, and agrees with, the Company the following:


 


a.
The Purchaser has the knowledge and experience in financial and business matters necessary to evaluate the merits and risks of its prospective
investment in the Company, and has carefully reviewed and understands the risks of, and other considerations relating to, the purchase
of Securities and the tax consequences of the investment, and has the ability to bear the economic risks of the investment. The Purchaser
can afford the loss of his, her or its entire investment.


 


b.
The Purchaser is acquiring the Securities for investment for his, her or its own account and not with the view to, or for resale in connection
with, any distribution thereof. The Purchaser understands and acknowledges that the Offering and sale of the Securities have not been
registered under the Securities Act or any state securities laws, by reason of a specific exemption from the registration provisions
of the Securities Act and applicable state securities laws, which depends upon, among other things, the bona fide nature of the investment
intent as expressed herein. The Purchaser further represents that he, she or it does not have any contract, undertaking, agreement or
arrangement with any person to sell, transfer or grant participation to any third person with respect to any of the Securities. The Purchaser
understands and acknowledges that the Offering of the Securities will not be registered under the Securities Act nor under the state
securities laws on the ground that the sale of the Securities to the Purchaser as provided for in this Agreement and the issuance of
securities hereunder is exempt from the registration requirements of the Securities Act and any applicable state securities laws. The
Purchaser is an “accredited investor” as defined in Rule 501 of Regulation D as promulgated by the SEC under the Securities
Act, for the reason(s) specified on the Accredited Investor Certification as completed by Purchaser, and Purchaser shall
submit to the Company such further assurances of such status as may be reasonably requested by the Company. The Purchaser resides in
the jurisdiction set forth on the Purchaser’s Omnibus Signature Page affixed hereto. The Purchaser has not taken any of the actions
set forth in, and is not subject to, the disqualification provisions of Rule 506(d)(1) of the Securities Act.


 



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c.
The Purchaser (i) if a natural person, represents that he or she is the greater of (A) 21 years of age or (B) the age of legal majority
in his or her jurisdiction of residence, and has full power and authority to execute and deliver this Agreement and all other related
agreements or certificates and to carry out the provisions hereof and thereof; (ii) if a corporation, partnership, limited liability
company, association, joint stock company, trust, unincorporated organization or other entity, represents that such entity was not formed
for the specific purpose of acquiring the Securities, such entity is duly organized, validly existing and in good standing under the
laws of the state or jurisdiction of its organization, the consummation of the transactions contemplated hereby is authorized by, and
will not result in a violation of state law or its charter or other organizational documents, such entity has full power and authority
to execute and deliver this Agreement and all other related agreements or certificates and to carry out the provisions hereof and thereof
and to purchase and hold the Securities, the execution and delivery of this Agreement has been duly authorized by all necessary action,
this Agreement has been duly executed and delivered on behalf of such entity and is a legal, valid and binding obligation of such entity;
or (iii) if executing this Agreement in a representative or fiduciary capacity, represents that he, she or it has full power and authority
to execute and deliver this Agreement in such capacity and on behalf of the subscribing individual, ward, partnership, trust, estate,
corporation, or limited liability company or partnership, or other entity for whom the Purchaser is executing this Agreement, and such
individual, partnership, ward, trust, estate, corporation, or limited liability company or partnership, or other entity has full right
and power to perform pursuant to this Agreement and make an investment in the Company, and represents that this Agreement constitutes
a legal, valid and binding obligation of such entity. The execution and delivery of this Agreement will not violate or be in conflict
with any order, judgment, injunction, agreement or controlling document to which the Purchaser is a party or by which it is bound.


 


d.
The Purchaser understands that the Units and Securities are being offered and sold to him, her or it in reliance on specific exemptions
from the registration requirements of United States federal and state securities laws and that the Company is relying in part upon the
truth and accuracy of, and such Purchaser’s compliance with, the representations, warranties, agreements, acknowledgments and understandings
of such Purchaser set forth herein in order to determine the availability of such exemptions and the eligibility of such Purchaser to
acquire such securities. The Purchaser further acknowledges and understands that the Company is relying on the representations and warranties
made by the Purchaser hereunder and that such representations and warranties are a material inducement to the Company to sell the Securities
to the Purchaser. The Purchaser further acknowledges that without such representations and warranties of the Purchaser made hereunder,
the Company would not enter into this Agreement with the Purchaser.


 


e.
(a) Unless the Purchaser has completed the Accredited Investor Certification, the Purchaser is not a U.S. Purchaser, the Purchaser
is resident outside of the United States and represents;


 


(i)
the Purchaser is knowledgeable of, or has been independently advised as to, the applicable securities laws having application in the
jurisdiction in which the Purchaser is resident (the “International Jurisdiction”) which would apply to the offer
and sale of the Securities;


 



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(ii)
the Purchaser is purchasing the Securities pursuant to exemptions from prospectus or equivalent requirements under applicable laws of
the International Jurisdiction or, if such is not applicable, the Purchaser is permitted to purchase the Securities under applicable
securities laws of the International Jurisdiction without the need to rely on any exemptions;


 


(iii)
the applicable laws and regulations of the International Jurisdiction do not and will not require the Company to make any filings or
seek any approvals of any kind from any securities regulator of any kind in the International Jurisdiction in connection with the offer,
issue, sale or resale of any of the Securities;


 


(iv)
the purchase of the Securities by the Purchaser does not trigger:


 


A.
any obligation to prepare and file a prospectus or similar document, or any other report with respect to such purchase in the International
Jurisdiction, or


 


B.
any continuous disclosure reporting obligation of the Companyin the International Jurisdiction, and


 


(v)
the Purchaser will, if requested by the Issuer, deliver to the Company a certificate or opinion of local counsel from the International
Jurisdiction which will confirm the matters referred to in subparagraphs (ii), (iii) and (iv) above to the satisfaction of the Issuer,
acting reasonably;


 


f.
The Purchaser understands that a limited public market exists for the Company’s Common Stock and that there can be no assurance
that any substantial public market for the Common Stock will exist or continue to exist.


 


g.
The Purchaser has received, reviewed and understood the information about the Company, and has had an opportunity to discuss the Company’s
business, management and financial affairs with the Company’s management. The Purchaser understands that such discussions, were
intended to describe the aspects of the Company’s business and prospects and the Offering which the Company believes to be material,
but were not necessarily a thorough or exhaustive description, and except as expressly set forth in this Agreement, the Company makes
no representation or warranty with respect to the completeness of such information and makes no representation or warranty of any kind
with respect to any information provided by any entity other than the Company. Some of such information may include projections as to
the future performance of the Company, which projections may not be realized, may be based on assumptions which may not be correct and
may be subject to numerous factors beyond the Company’s control. The Purchaser acknowledges that he, she or it is not relying upon
any person or entity, other than the Company and its officers and directors, in making its investment or decision to invest in the Company.
Additionally, the Purchaser understands and represents that he, she or it is purchasing the Securities notwithstanding the fact that
the Company may disclose in the future certain material information the Purchaser has not received, including (without limitation) financial
statements of the Company and/or IR-Med for the current or prior fiscal periods, and any subsequent period financial statements that
will be filed with the SEC, that he, she or it is not relying on any such information in connection with his, her or its purchase of
the Securities and that he, she or it waives any right of action with respect to the nondisclosure to him, her or it prior to his, her
or its purchase of the Securities of any such information. Each Purchaser has sought such accounting, legal and tax advice as the Purchaser
has considered necessary to make an informed investment decision with respect to his, her or its acquisition of the Securities.


 



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h.
The Purchaser acknowledges that the Company is not acting as a financial advisor or fiduciary of the Purchaser (or in any similar capacity)
with respect to the Transaction Documents and the transactions contemplated hereby and thereby, and no investment advice has been given
by the Company or any of their respective representatives or agents in connection with the Transaction Documents and the transactions
contemplated hereby and thereby. The Purchaser further represents to the Company that the Purchaser’s decision to enter into the
Transaction Documents has been based solely on the independent evaluation by the Purchaser and the Purchaser’s representatives,
as well as the provisions of the Transaction Documents.


 


i.
As of the applicable Closing, all actions on the part of Purchaser, and its officers, directors and partners, if applicable, necessary
for the authorization, execution and delivery of this Agreement and the performance of all obligations of the Purchaser hereunder and
thereunder shall have been taken, and this Agreement, assuming due execution by the parties hereto and thereto, constitute valid and
legally binding obligations of the Purchaser, enforceable in accordance with their respective terms, subject to: (i) judicial principles
limiting the availability of specific performance, injunctive relief, and other equitable remedies and (ii) bankruptcy, insolvency, reorganization,
moratorium or other similar laws now or hereafter in effect generally relating to or affecting creditors’ rights.


 


j.
Purchaser represents that neither it nor, to its knowledge, any person or entity controlling, controlled by or under common control with
it, nor any person having a beneficial interest in the Purchaser, nor any person on whose behalf the Purchaser is acting: (i) is a person
listed in the Annex to Executive Order No. 13224 (2001) issued by the President of the United States (Executive Order Blocking Property
and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism); (ii) is named on the List of Specially
Designated Nationals and Blocked Persons maintained by the U.S. Office of Foreign Assets Control; (iii) is a non-U.S. shell bank or is
providing banking services indirectly to a non-U.S. shell bank; (iv) is a senior non-U.S. political figure or an immediate family member
or close associate of such figure; or (v) is otherwise prohibited from investing in the Company pursuant to applicable U.S. anti-money
laundering, anti-terrorist and asset control laws, regulations, rules or orders (categories (i) through (v), each a “Prohibited
Purchaser”). The Purchaser agrees to provide the Company, promptly upon request, all information that the Company reasonably
deems necessary or appropriate to comply with applicable U.S. anti-money laundering, anti-terrorist and asset control laws, regulations,
rules and orders. The Purchaser consents to the disclosure to U.S. regulators and law enforcement authorities by the Company and its
Affiliates and agents of such information about the Purchaser as the Company reasonably deems necessary or appropriate to comply with
applicable U.S. anti-money laundering, anti-terrorist and asset control laws, regulations, rules and orders. If the Purchaser is a financial
institution that is subject to the USA Patriot Act, the Purchaser represents that it has met all of its obligations under the USA Patriot
Act. The Purchaser acknowledges that if, following its investment in the Company, the Company reasonably determines that the Purchaser
is a Prohibited Purchaser or is otherwise engaged in suspicious activity or refuses to promptly provide information that the Company
requests, the Company has the right or may be obligated to prohibit additional investments, segregate the assets constituting the investment
in accordance with applicable regulations or immediately require the Purchaser to transfer the Securities. The Purchaser further acknowledges
that neither the Purchaser nor any of the Purchaser’s Affiliates or agents will have any claim against the Company for any form
of damages as a result of any of the foregoing actions.


 






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k.
If the Purchaser is Affiliated with a non-U.S. banking institution (a “Foreign Bank”), or if the Purchaser
receives deposits from, makes payments on behalf of, or handles other financial transactions related to a Foreign Bank, the Purchaser
represents and warrants to the Company that: (1) the Foreign Bank has a fixed address, other than solely an electronic address, in a
country in which the Foreign Bank is authorized to conduct banking activities; (2) the Foreign Bank maintains operating records related
to its banking activities; (3) the Foreign Bank is subject to inspection by the banking authority that licensed the Foreign Bank to conduct
banking activities; and (4) the Foreign Bank does not provide banking services to any other Foreign Bank that does not have a physical
presence in any country and that is not a regulated Affiliate.


 


l.
The Purchaser or its duly authorized representative realizes that because of the inherently speculative nature of businesses of the kind
conducted and contemplated by the Company, the Company’s financial results may be expected to fluctuate from month to month and
from period to period and will, generally, involve a high degree of financial and market risk that could result in substantial or, at
times, even total losses for investors in securities of the Company.


 


m.
The Purchaser has adequate means of providing for its current and anticipated financial needs and contingencies, is able to bear the
economic risk for an indefinite period of time and has no need for liquidity of the investment in the Securities and could afford complete
loss of such investment.


 


n.
The Purchaser is not subscribing for Securities as a result of or subsequent to any advertisement, article, notice or other communication,
published in any newspaper, magazine or similar media or broadcast over television, radio, or the internet, or presented at any seminar
or meeting, or any solicitation of a subscription by a person not previously known to the Purchaser in connection with investments in
securities generally.


 


o.
The Purchaser acknowledges that no U.S. federal or state agency or any other government or governmental agency has passed upon the Securities
or made any finding or determination as to the fairness, suitability or wisdom of any investments therein.


 


p.
Other than consummating the transactions contemplated hereunder, the Purchaser has not directly or indirectly, nor has any individual
or entity acting on behalf of or pursuant to any understanding with such Purchaser, executed any purchases or sales, including Short
Sales, of the securities of the Company during the period commencing as of the time that such Purchaser first received a term sheet (written
or oral) from the Company or any other individual or entity representing the Company setting forth the material terms of the transactions
contemplated hereunder and ending immediately prior to the execution hereof. Notwithstanding the foregoing, in the case of a Purchaser
that is a multi-managed investment vehicle whereby separate portfolio managers manage separate portions of such Purchaser’s assets
and the portfolio managers have no direct knowledge of the investment decisions made by the portfolio managers managing other portions
of such Purchaser’s assets, the representation set forth above shall only apply with respect to the portion of assets managed by
the portfolio manager that made the investment decision to purchase the Securities covered by this Agreement. Other than to other individuals
or entities party to this Agreement, such Purchaser has maintained the confidentiality of all disclosures made to it in connection with
this transaction (including the existence and terms of this transaction). Notwithstanding the foregoing, for avoidance of doubt, nothing
contained herein shall constitute a representation or warranty, or preclude any actions, with respect to the identification of the availability
of, or securing of, available shares to borrow in order to effect Short Sales or similar transactions in the future. For purposes of
this Agreement, “Short Sales” means all “short sales” as defined in Rule 200 of Regulation SHO
under the Exchange Act (but shall not be deemed to include the location and/or reservation of borrowable shares of Common Stock).


 



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q.
The Purchaser is aware that the anti-manipulation rules of Regulation M under the Exchange Act may apply to sales of the Securities and
other activities with respect to the Securities by the Purchaser.


 


r.
All of the information concerning the Purchaser set forth herein, and any other information furnished by the Purchaser in writing to
the Company for use in connection with the transactions contemplated by this Agreement, is true, correct and complete in all material
respects as of the date of this Agreement, and, if there should be any material change in such information prior to the Purchaser’s
purchase of the Units and Securities, the Purchaser will promptly furnish revised or corrected information to the Company.


 


s.
The Purchaser has reviewed with its own tax advisors the U.S. federal, state, local and foreign tax consequences of this investment and
the transactions contemplated by the Transaction Documents. With respect to such matters, such Purchaser relies solely on such advisors
and not on any statements or representations of the Company or any of its agents, written or oral. The Purchaser understands that it
(and not the Company) shall be responsible for its own tax liability that may arise as a result of this investment or the transactions
contemplated by the Transaction Documents.


 


t.
If the Purchaser is not a United States person (as defined by Section 7701(a)(30) of the Internal Revenue Code of 1986, as amended),
the Purchaser hereby represents that it has satisfied itself as to the full observance of the laws of its jurisdiction in connection
with any invitation to subscribe for the Securities or any use of this Agreement, including (a) the legal requirements within its jurisdiction
for the purchase of the Securities; (b) any foreign exchange restrictions applicable to such purchase; (c) any governmental or other
consents that may need to be obtained; and (d) the income tax and other tax consequences, if any, that may be relevant to the purchase,
holding, redemption, sale or transfer of the Securities. The Purchaser’s subscription and payment for and continued beneficial
ownership of the Securities will not violate any applicable securities or other laws of the Purchaser’s jurisdiction.


 


u.
(For ERISA plans only) The fiduciary of the Employee Retirement Income Security Act of 1974 (“ERISA”)
plan (the “Plan”) represents that such fiduciary has been informed of and understands the Company’s investment
objectives, policies and strategies, and that the decision to invest “plan assets” (as such term is defined in ERISA) in
the Company is consistent with the provisions of ERISA that require diversification of plan assets and impose other fiduciary responsibilities.
The Purchaser fiduciary or Plan (a) is responsible for the decision to invest in the Company; (b) is independent of the Company or any
of its Affiliates; (c) is qualified to make such investment decision; and (d) in making such decision, the Purchaser fiduciary or Plan
has not relied primarily on any advice or recommendation of the Company or any of its Affiliates.


 


v.
Neither the Purchaser nor, to the Purchaser’s knowledge, any of its directors, executive officers, other officers that may serve
as a director or officer of any company in which it invests, general partners or managing members is subject to any Disqualification
Events, except for Disqualification Events covered by Rule 506(d)(2)(ii) or (iii) under the Securities Act, and disclosed in writing
in reasonable detail to the Company.


 






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w.
The Purchaser understands that there are substantial restrictions on the transferability of the Securities and that the certificates
representing the Securities shall bear a restrictive legend in substantially the following form (and a stop-transfer order may be placed
against transfer of such certificates or other instruments):


 


THE
SECURITIES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES
ACT”), OR ANY STATE SECURITIES LAWS, AND NEITHER SUCH SECURITIES NOR ANY INTEREST THEREIN MAY BE OFFERED, SOLD, PLEDGED,
ASSIGNED OR OTHERWISE TRANSFERRED UNLESS (1) A REGISTRATION STATEMENT WITH RESPECT THERETO IS EFFECTIVE UNDER THE SECURITIES ACT AND
ANY APPLICABLE STATE SECURITIES LAWS, OR (2) AN EXEMPTION FROM SUCH REGISTRATION EXISTS AND THE COMPANY RECEIVES AN OPINION OF COUNSEL,
WHICH COUNSEL AND OPINION ARE REASONABLY SATISFACTORY TO THE COMPANY, THAT SUCH SECURITIES MAY BE OFFERED, SOLD, PLEDGED, ASSIGNED OR
TRANSFERRED IN THE MANNER CONTEMPLATED WITHOUT AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR APPLICABLE STATE SECURITIES
LAWS OR (3) SOLD PURSUANT TO RULE 144 UNDER THE SECURITIES ACT.


 


x.
If the Purchaser is an individual, then the Purchaser resides in the state or province identified in the address of the Purchaser set
forth on such Purchaser’s Omnibus Signature Page to this Agreement; if the Purchaser is a partnership, corporation, limited liability
company or other entity, then the office or offices of the Purchaser in which its principal place of business is identified in the address
or addresses of the Purchaser set forth on such Purchaser’s Omnibus Signature Page to this Agreement.


 


y.
The Purchaser understands that the Company was formerly a “shell company” as defined in Rule 12b-2 under the Exchange
Act. Pursuant to Rule 144(i), securities issued by a current or former shell company (that is, the Securities) that otherwise meet the
holding period and other requirements of Rule 144 nevertheless cannot be sold in reliance on Rule 144 unless the Company is subject to
the reporting requirements of Section 13 or 15(d) of the Exchange Act and has filed all reports and other materials required to be filed
by Section 13 or 15(d) of the Exchange Act, as applicable, during the preceding 12 months (or for such shorter period that the issuer
was required to file such reports and materials), other than Form 8-K reports. As a result, the restrictive legends on certificates for
the Securities cannot be removed except in connection with an actual sale meeting the foregoing requirements or pursuant to an effective
registration statement.


 


4.
Conditions to Closing.


 


(i)
The Company’s obligation to complete the sale and issuance of the Units and deliver the Securities at the Closing shall be
subject to the following conditions to the extent not waived by the Company:


 


a.
Receipt of Payment. The Company shall have received payment, by certified or other bank check or by wire transfer of immediately
available funds, in the full amount of the purchase price for the number of Units being purchased by such Purchaser at such Closing.


 


b.
Representations and Warranties. The representations and warranties made by the Purchaser in Section 3 hereof shall be true and
correct in all respects when made, and shall be true and correct in all respects on the applicable Closing date with the same force and
effect as if they had been made on and as of said date.


 


c.
Performance. The Purchaser shall have performed in all material respects all obligations and covenants herein required to be performed
by it on or prior to the applicable Closing.


 






    	10



     


    

 





d.
Receipt of Executed Documents. The Purchaser shall have executed and delivered to the Company the Signature Page, the Purchaser
Questionnaire.


 


e.
Qualifications. All authorizations, approvals or permits, of any governmental authority or regulatory body of the United States
or of any state that are required in connection with the lawful issuance and sale of the Securities pursuant to this Agreement shall
be obtained and effective as of such Closing except for Blue Sky law permits and qualifications that may be properly obtained after such
Closing.


 


(ii)
The Purchaser’s obligation to complete the purchase of the Units and remit the purchase price shall be subject to the following
conditions to the extent not waived by the Purchaser:


 


a.
Representations and Warranties. The representations and warranties made by the Company in Section 2 hereof shall be true and correct
in all respects when made, and shall be true and correct in all respects on the applicable Closing date with the same force and effect
as if they had been made on and as of said date.


 


b.
Performance. The Company shall have performed in all material respects all obligations and covenants herein required to be performed
by it on or prior to the applicable Closing.


 


c.
Receipt of Executed Documents. The Company shall have executed and delivered to the Purchaser the Signature Page and the Warrant
instrument.


 


d.
Qualifications. All authorizations, approvals or permits, of any governmental authority or regulatory body of the United States
or of any state that are required in connection with the lawful issuance and sale of the Securities pursuant to this Agreement shall
be obtained and effective as of such Closing except for Blue Sky law permits and qualifications that may be properly obtained after such
Closing.


 


5.
Registration. Within 120 days after the closing of the Offering, the Company shall
file registration statement on Form S-1 under the Securities Act covering the resale by the Purchaser of all Registrable Securities held
by the Purchaser.


 


“Registrable
Securities” shall mean (i) the Common Stock in the Units purchased by the Purchaser hereunder and (ii) the shares of Common Stock
issuable upon exercise of the Warrants included in the purchased Units.


 


The
registration expenses (other than underwriting discounts and commissions, if any) will be borne by the Company.


 


6.
Indemnification. The Purchaser will indemnify and hold harmless the Company and, where applicable, its directors, officers,
employees, agents, advisors and shareholders, from and against any and all loss, liability, claim, damage and expense whatsoever (including,
but not limited to, any and all fees, costs and expenses whatsoever reasonably incurred in investigating, preparing or defending against
any claim, lawsuit, administrative proceeding or investigation whether commenced or threatened) arising out of or based upon any representation
or warranty of the Purchaser contained in this Agreement or the Questionnaire being untrue in any material respect, or any breach or
failure by the Purchaser to comply with any covenant or agreement made by the Purchaser to the Company in connection therewith; provided,
that the Purchaser’s maximum liability to the Company, its affiliates and the other individuals and entities referenced herein
shall be twice the Purchase Price, except to the extent that such liability results from a breach by the Purchaser of its representations
in Section 3(b) and/or the Accredited Investor Certification.


 



    	11



     


    

 





7.
Non-Revocability; Binding Effect. The subscription hereunder may not be revoked prior to the Closing thereon. The Purchaser
hereby acknowledges and agrees that this Agreement shall survive the death or disability of the Purchaser and shall be binding upon and
inure to the benefit of the parties and their heirs, executors, administrators, successors, legal representatives and permitted assigns.
If the Purchaser is more than one person, the obligations of the Purchaser hereunder shall be joint and several and the agreements, representations,
warranties and acknowledgments herein shall be deemed to be made by and be binding upon each such person and such person’s heirs,
executors, administrators, successors, legal representatives and permitted assigns. For the purposes of this Agreement, “Business
Day” means a day, other than a Saturday or Sunday, on which banks in New York City are open for the general transaction
of business.


 


8.
Miscellaneous.


 


a.
Modification. This Agreement shall not be amended, modified or waived except by an instrument in writing signed by the
Company and the Purchaser.


 


b.
No Third-Party Beneficiary. This Agreement is intended for the benefit of the parties hereto and their respective successors
and permitted assigns and is not for the benefit of, nor may any provision hereof be enforced by, any other Person.


 


c.
Notices. Any notice, consents, waivers or other communication required or permitted to be given hereunder shall be in writing
and will be deemed to have been delivered: (i) upon receipt, when personally delivered; (ii) upon receipt when sent by certified mail,
return receipt requested, postage prepaid; (iii) upon receipt, when sent by facsimile (provided confirmation of transmission is mechanically
or electronically generated and kept on file by the sending party; (iv) when sent, if by e- mail, (provided that such sent e-mail is
kept on file (whether electronically or otherwise) by the sending party and the sending party does not receive an automatically generated
message from the recipient’s e- mail server that such e-mail could not be delivered to such recipient); or (v) one (1) Business
Day after deposit with an overnight courier service with next day delivery specified, in each case, properly addressed to the party to
receive the same. The addresses, facsimile numbers and email addresses for such communications shall be:


(a)
if to the Company, at


 


c/o
Aboudi Legal Group PLLC


745
Fifth Avenue


New
York, NY 10151


Attention:
Sharon Levkoviz


Email:
Sharon Levkoviz (Sharon@ir-medical.com)


 





with
copies (which shall not constitute notice) to:


 


Aboudi
Legal Group PLLC


745
Fifth Avenue


New
York, NY 10151


Attention:
David Aboudi


 


E-mail:
david@aboudilegal.com


 



    	12



     


    

 





(b)
if to the Purchaser, at the address set forth on the Signature Page hereof


 


(or,
in either case, to such other address as the party shall have furnished in writing in accordance with the provisions of this Section).
Any notice or other communication given by certified mail shall be deemed given at the time of certification thereof, except for a notice
changing a party’s address which shall be deemed given at the time of receipt thereof.


 


d.
Assignability. This Agreement and the rights, interests and obligations hereunder are not transferable or assignable by
the Purchaser, and the transfer or assignment of the Shares shall be made only in accordance with all applicable laws.


 


e.
Applicable Law. This Agreement shall be governed by and construed in accordance with the laws of the State of New York,
without reference to the principles thereof relating to the conflict of laws. The parties hereby submit to the exclusive jurisdiction
of the appropriate federal or state court sitting in New York County.


 


f.
RESERVED


 


g.
This Agreement, all exhibits, schedules and attachments hereto and thereto and any confidentiality agreement between the Purchaser and
the Company, constitute the entire agreement between the Purchaser and the Company with respect to the Offering and supersede all prior
oral or written agreements and understandings, if any, relating to the subject matter hereof. The terms and provisions of this Agreement
may be waived, or consent for the departure therefrom granted, only by a written document executed by the party entitled to the benefits
of such terms or provisions.


 


h.
If the Securities are certificated and any certificate or instrument evidencing any Securities is mutilated, lost, stolen or destroyed,
the Company shall issue or cause to be issued in exchange and substitution for and upon cancellation thereof, or in lieu of and substitution
therefor, a new certificate or instrument, but only upon receipt of evidence reasonably satisfactory to the Company and the Company’s
transfer agent of such loss, theft or destruction and the execution by the holder thereof of a customary lost certificate affidavit of
that fact and an agreement to indemnify and hold harmless the Company and the Company’s transfer agent for any losses in connection
therewith or, if required by the transfer agent, a bond in such form and amount as is required by the transfer agent. The applicants
for a new certificate or instrument under such circumstances shall also pay any reasonable third-party costs associated with the issuance
of such replacement Securities. If a replacement certificate or instrument evidencing any Securities is requested due to a mutilation
thereof, the Company may require delivery of such mutilated certificate or instrument as a condition precedent to any issuance of a replacement.


 


i.
Each of the parties hereto shall pay its own fees and expenses (including the fees of any attorneys, accountants, appraisers or others
engaged by such party) in connection with this Agreement and the transactions contemplated hereby, whether or not the transactions contemplated
hereby are consummated.


 


j.
This Agreement may be executed in one or more original or facsimile or by an e-mail which contains a portable document format (.pdf)
file of an executed signature page counterparts, each of which shall be deemed an original, but all of which shall together constitute
one and the same instrument and which shall be enforceable against the parties actually executing such counterparts. The exchange of
copies of this Agreement and of signature pages by facsimile transmission or in .pdf format shall constitute effective execution and
delivery of this Agreement as to the parties and may be used in lieu of the original Agreement for all purposes. Signatures of the parties
transmitted by facsimile or by e-mail of a document in pdf format shall be deemed to be their original signatures for all purposes.


 



    	13



     


    

 





k.
Each provision of this Agreement shall be considered separable and, if for any reason any provision or provisions hereof are determined
to be invalid or contrary to applicable law, such invalidity or illegality shall not impair the operation of or affect the remaining
portions of this Agreement.


 


l.
The Purchaser hereby agrees to furnish the Company such other information as the Company may reasonably request prior to the applicable
Closing with respect to its subscription hereunder.


 


m.
The representations and warranties of the Company and each Purchaser contained in or made pursuant to this Agreement shall survive the
execution and delivery of this Agreement for a period of one (1) year from the date of the Initial Closing and shall in no way be affected
by any investigation or knowledge of the subject matter thereof made by or on behalf of the Purchasers or the Company.


 


n.
Public Disclosure. Neither the Purchaser nor any officer, manager, director, member, partner, stockholder, employee, Affiliate,
Affiliated person or entity of the Purchaser shall make or issue any press releases or otherwise make any public statements or make any
disclosures to any third person or entity with respect to the transactions contemplated herein and will not make or issue any press releases
or otherwise make any public statements of any nature whatsoever with respect to the Company without the Company’s express prior
approval (which may be withheld in the Company’s sole discretion), except to the extent such disclosure is required by law, request
of the staff of the SEC or of any regulatory agency or principal trading market regulations.


 


o.
Independent Nature of Each Purchaser’s Obligations and Rights. For avoidance of doubt, the obligations of the Purchaser
under this Agreement are several and not joint with the obligations of any other Purchaser, and the Purchaser shall not be responsible
in any way for the performance of the obligations of any other Purchaser under any other Subscription Agreement. Nothing contained herein
and no action taken by the Purchaser shall be deemed to constitute the Purchaser as a partnership, an association, a joint venture, or
any other kind of entity, or create a presumption that the Purchasers are in any way acting in concert or as a group with respect to
such obligations or the transactions contemplated by this Agreement and any other Subscription Agreements. The Purchaser shall be entitled
to independently protect and enforce its rights, including without limitation the rights arising out of this Agreement, and it shall
not be necessary for any other Purchaser to be joined as an additional party in any proceeding for such purpose.


 


p.
Waiver of Conflicts. Each party to this Agreement acknowledges that Aboudi Legal Group PLLC represented the Company and
IR-Med, respectively, in the transaction contemplated by this Agreement and has not represented any individual Purchaser in connection
with such transaction. Further, each party to this Agreement hereby acknowledges that Aboudi Legal Group PLLC anticipates that it will
continue to advise the Company following the closing of the Offering.


 


[Signature
page follows.]


 




    	14



     


    

 


IN
WITNESS WHEREOF, the Purchaser hereby irrevocably subscribes for and agrees to purchase from Securities in the amount set forth below
as of the day of April, 2022.


 


	___________	 	X	 	+
                $
	Number
    of Units	 	$
    per Unit	 	Purchase
    Price


 


	PURCHASER
    (individual)	 	PURCHASER
    (entity)
	 	 	 	 
	 	 	 
	Signature	 	Name of Entity
	 	 	 	 
	 	 	 By:	 
	Print
    Name	 	 	 Signature
	 	 	 	 
	 	 	 Print
    Name:_________
	Signature
                                            (if Joint Tenants or

                                                         Tenants
                                            in Common)
	 	 Title:
    	___________________ 
	 	 	 	 
	Address
    of Principal Residence:	 	 	Address
    of Executive Offices:
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	Social
    Security Number(s):	 	 	IRS
    Tax Identification Number:
	 	 	 	 
	 	 	 	 
	Telephone
    Number:	 	 	Telephone
    Number:
	 	 	 	 
	 	 	 	 
	Facsimile
    Number:	 	 	Facsimile
    Number:
	 	 	 	 
	 	 	 	 
	E-mail
    Address:	 	 	E-mail
    Address:
	 	 	 	 


 




    	15



     


    

 


ACCEPTANCE


 


The
Company hereby accepts the Subscription (as defined herein) on the terms and conditions contained in this private placement subscription
agreement (this “Agreement”) as of the ___ day of ______ 2022 (the “Closing Date”).


 


	IR-MED,
    INC.	 
	 	 	 
	Per:	 	 
	 	 Authorized
    Signatory	 


 




    	16



     


    

 


IR-MED,
INC.


ACCREDITED
INVESTOR CERTIFICATION


For
Individual Investors Only


(all
Individual Investors must INITIAL where appropriate):


 


	Initial
    ________	 	I
    have a net worth of at least US$1 million either individually or through aggregating my individual holdings and those in which I
    have a joint, community property or other similar shared ownership interest with my spouse. (For purposes of calculating your
    net worth under this paragraph, (a) your primary residence shall not be included as an asset; (b) indebtedness secured by
    your primary residence, up to the estimated fair market value of your primary residence at the time of your purchase of the securities,
    shall not be included as a liability (except that if the amount of such indebtedness outstanding at the time of your purchase of
    the securities exceeds the amount outstanding 60 days before such time, other than as a result of the acquisition of your primary
    residence, the amount of such excess shall be included as a liability); and (c) indebtedness that is secured by your primary residence
    in excess of the estimated fair market value of your primary residence at the time of your purchase of the securities shall be included
    as a liability.)
	 	 
	Initial
    ________	 	I
    have had an annual gross income for the past two years of at least US$200,000 (or US$300,000 jointly with my spouse) and expect my
    income (or joint income, as appropriate) to reach the same level in the current year.
	 	 
	Initial
    ________	 	I
    am a director or executive officer of IR-Med, Inc .
	 	 
	 	For
    Non-Individual Investors (Entities)
	 	(all
    Non-Individual Investors must INITIAL where appropriate):
	 	 
	Initial
    ________	 	The
    investor certifies that it is a partnership, corporation, limited liability company or business trust that is 100% owned by persons
    who meet at least one of the criteria for Individual Investors set forth above (in which case each such person must complete the
    Accreditor Investor Certification for Individuals above as well the remainder of this questionnaire).
	 	 
	Initial
    ________	 	The
    investor certifies that it is a partnership, corporation, limited liability company or business trust that has total assets of at
    least US$5 million and was not formed for the purpose of investing the Company.
	 	 
	Initial
    ________	 	The
    investor certifies that it is an employee benefit plan whose investment decision is made by a plan fiduciary (as defined in ERISA
    § 3(21)) that is a bank, savings and loan association, insurance company or registered investment advisor.
	 	 
	Initial
    ________	 	The
    investor certifies that it is an employee benefit plan whose total assets exceed US$5,000,000 as of the date of this Agreement.
	 	 	 
	Initial
    ________	 	The
    undersigned certifies that it is a self-directed employee benefit plan whose investment decisions are made solely by persons who
    meet at least one of the criteria for Individual Investors.



 



    	17



     


    

 





	Initial
    ________	 	The
    investor certifies that it is a U.S. bank as defined in Section 3(a)(2) of the Securities Act, or any U.S. savings and loan association
    or other similar U.S. institution as defined in Section 3(a)(5) of the Securities Act acting in its individual or fiduciary capacity.
	 	 
	Initial
    ________	 	The
    undersigned certifies that it is a broker-dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934.
	 	 
	Initial
    ________	 	The
    investor certifies that it is an organization described in Section 501(c)(3) of the Internal Revenue Code with total assets exceeding
    US$5,000,000 and not formed for the specific purpose of investing in the Company.
	 	 
	Initial
    ________	 	The
    investor certifies that it is a trust with total assets of at least US$5,000,000, not formed for the specific purpose of investing
    in the Company, and whose purchase is directed by a person with such knowledge and experience in financial and business matters that
    such person is capable of evaluating the merits and risks of the prospective investment.
	 	 	 
	Initial
    ________	 	The
    investor certifies that it is a plan established and maintained by a state or its political subdivisions, or any agency or instrumentality
    thereof, for the benefit of its employees, and which has total assets in excess of US$5,000,000.
	 	 
	Initial
    ________	 	The
    investor certifies that it is an insurance company as defined in Section 2(13) of the Securities Act of 1933, or a registered investment
    company.


 




    	18



     


    

  


Investor
Profile


(Must
be completed by Investor)


Section
A - Personal Investor Information


Investor
Name(s):___________________________________________________


Individual
executing Profile or Trustee:__________________________________________________________________


Year
of Birth:__________________________________________________ Investment Experience (Years):___________


Home
Street Address:_______________________________________________________________________________


Home
City, State & Zip Code:_________________________________________________________________________


Home
Phone:______________________________ Home Fax:_______________________________ mail:____________


Employer:________________________________________________________________________________________




Employer
Street Address:____________________________________________________________________________


Employer
City, State & Zip Code:______________________________________________________________________


Bus.
Phone:_________________________________Bus. Fax:________________________________________Bus. Email:__________________________


Type
of Business:_________________________________________________________________________________


Outside
Broker/Dealer:


Section
B – Certificate Delivery Instructions


 


Please
deliver certificate to the Employer Address listed in Section A.


Please
deliver certificate to the Home Address listed in Section A.


Please
deliver certificate to the following address:


 


Section
C – Form of Payment – Check or Wire Transfer


 


Check
payable to [●]


Wire
funds from my outside account according to Section 2(b) of the Subscription Agreement.


The
funds for this investment are rolled over, tax deferred from within the allowed 60-day window.


Please
check if you are a FINRA member or Affiliate of a FINRA member firm:


 








	 	 	 
	 	 	 
	Investor Signature	 	Date


  







    	19



     


    

 


ANTI
MONEY LAUNDERING REQUIREMENTS


 


The
USA PATRIOT Act


 


The
USA PATRIOT Act is designed to detect, deter, and punish terrorists in the United States and abroad. The Act imposes new anti-money laundering
requirements on brokerage firms and financial institutions. Since April 24, 2002 all brokerage firms have been required to have new,
comprehensive anti-money laundering programs.


 


To
help you understand these efforts, we want to provide you with some information about money laundering and our steps to implement the
USA PATRIOT Act.


 


What
is money laundering?


 


Money
laundering is the process of disguising illegally obtained money so that the funds appear to come from legitimate sources or activities.
Money laundering occurs in connection with a wide variety of crimes, including illegal arms sales, drug trafficking, robbery, fraud,
racketeering, and terrorism.


 


How
big is the problem and why is it important?


 


The
use of the U.S. financial system by criminals to facilitate terrorism or other crimes could well taint our financial markets. According
to the U.S. State Department, one recent estimate puts the amount of worldwide money laundering activity at $1 trillion a year.


 


What
are we required to do to eliminate money laundering?


 


Under
rules required by the USA PATRIOT Act, our anti-money laundering program must designate a special compliance officer, set up employee
training, conduct independent audits, and establish policies and procedures to detect and report suspicious transaction and ensure compliance
with such laws. As part of our required program, we may ask you to provide various identification documents or other information. Until
you provide the information or documents we need, we may not be able to effect any transactions for you.


 






    	20



     


    

 


ANTI-MONEY
LAUNDERING INFORMATION FORM


 


The
following is required in accordance with the AML provision of the USA PATRIOT ACT.


 


(Please
fill out and return with requested documentation.)


 


INVESTOR
NAME:______________________________________________


 


LEGAL
ADDRESS:_______________________________________________________________________________


  


INVESTMENT
OBJECTIVE:________________________________________________________________________


 


FOR
INVESTORS WHO ARE ENTITIES: TYPE OF BUSINESS:_____________________________________________


 










IDENTIFICATION
& DOCUMENTATION AND SOURCE OF FUNDS:


 


	1.	Please
    submit a copy of non-expired identification for the authorized signatory(ies) on the investment documents, showing name, date of
    birth, address and signature. The address shown on the identification document MUST match the Investor’s address shown on
    the Investor Signature Page.


 


	 	 	 	 	 	 	 	 	 
	 Current
    Driver’s License	 	or	 	Valid
    Passport	 	or	 	Identity
    Card


(Circle
one or more)


 


	2.	If
    the Investor is a corporation, limited liability company, trust or other type of entity, please submit the following requisite documents:
    (i) Certificate of Incorporation, By-Laws, Certificate of Formation, Operating Agreement, Trust or other similar documents for the
    type of entity; and (ii) Corporate Resolution or power of attorney or other similar document granting authority to signatory(ies)
    and designating that they are permitted to make the proposed investment.


 


	3.	Please
    advise where the funds were derived from to make the proposed investment:


 


	 	 	 	 	 	 	 
	 Investments	 	Savings	 	Proceeds
    of Sale	 	Other
      ______


(Circle
one or more)


 


	 
	Signature: _____________________________
	 
	Print
    Name: ____________________________
	 
	Title
    (if applicable): ______________________
	 
	Date:_________________________________


 




    	21