ex10x1.htm


    Exhibit
10.1

     

    Execution
Copy

     

    SUBSCRIPTION
AGREEMENT

     

    


     

    AspenBio
Pharma, Inc.

    1585
South Perry Street

    Castle
Rock, CO 80104

    


    Gentlemen:

    


    The undersigned (the “Investor”) hereby confirms its
agreement with AspenBio Pharma, Inc., a Colorado corporation (the “Company”), 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 the Company and the Investor.

     

    2.  The
Company has authorized the sale and issuance to certain investors of up to an
aggregate of 2,409,639 units (the “Units”), subject to adjustment
by the Company’s Board of Directors or a committee thereof, with each Unit
consisting of (i) one share (the “Share,” collectively, the
“Shares”) of its common
stock, no par value per share (the “Common Stock”), and (ii) one
warrant (the “Warrant,”
collectively, the “Warrants”) to purchase .285
shares of Common Stock (and the fractional amount being the “Warrant Ratio”), in
substantially the form attached hereto as Exhibit B, for a
purchase price of $4.15 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 (a) an effective Registration Statement on Form S-3, No. 333-159249,
as amended (the “Registration
Statement”) filed by the Company with the Securities and Exchange
Commission (the “Commission”), including the
Prospectus contained therein (the “Base Prospectus”), (b) if
applicable, certain “free writing prospectuses” (as that term is defined in Rule
405 under the Securities Act of 1933, as amended (the “Act”)), that have been or will
be filed, if required, with the Commission and delivered to the Investor on or
prior to the date hereof (the “Issuer Free Writing
Prospectus”), containing certain supplemental information regarding the
Units, the terms of the Offering and the Company, (c) a Preliminary Prospectus
Supplement (the “Preliminary Prospectus Supplement”), if
any, containing certain supplemental information regarding the Securities, the
terms of the Offering and the Company and
(d) a Prospectus Supplement (the “Prospectus Supplement” and,
together with the Base Prospectus, the “Prospectus”) containing
certain supplemental information regarding the Units and terms of the Offering
that will be filed with the Commission and delivered to the Investor (or made
available to the Investor by the filing by the Company of an electronic version
thereof with the Commission).

     

    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 Lazard Capital Markets LLC (“LCM” or the “Placement Agent”) 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 as follows

     

    Delivery
versus payment (“DVP”)
through DTC (i.e., on the Closing
Date, the Company shall deliver Shares registered in the Investor’s name and
address as set forth below and released by Corporate Stock Transfer, Inc., the
Company’s “Transfer
Agent”, to the Investor through DTC at the Closing directly to the
account(s) at LCM identified by the Investor; upon receipt of such Shares, LCM
shall promptly electronically deliver such Shares to 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.

                

              


      

    

     

    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 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 SHARES AND WARRANTS MAY NOT BE DELIVERED AT CLOSING TO
THE INVESTOR OR THE INVESTOR MAY BE EXCLUDED FROM THE CLOSING
ALTOGETHER.

     

    6.           The
executed Warrant 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
member of the Financial Industry Regulatory Authority, Inc. or an Associated
Person (as such term is defined under the NASD Membership and Registration Rules
Section 1011) as of the Closing, and (c) neither the Investor nor any group of
Investors (as identified in a public filing made with the Commission) of which
the Investor is a part in connection with the Offering of the Units, acquired,
or obtained the right to acquire, 20% or more of the Common Stock (or securities
convertible into or exercisable for Common Stock) or the voting power of the
Company on a post-transaction basis.  Exceptions:

    
 

    
      
        
          
(If
no exceptions, write “none.” If left blank, response will be deemed to be
“none.”)

      

       

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.           The
Investor represents that it has received (or otherwise had made available to it
by the filing by the Company of an electronic version thereof with the
Commission) the Base Prospectus, declared effective by the Commission on June 4,
2009, which is a part of the Company’s Registration Statement and the documents
incorporated by reference therein and any free writing prospectus (collectively,
the “Disclosure
Package”), prior to or in connection with the receipt of this
Agreement.  The Investor acknowledges that, prior to the delivery of
this Agreement to the Company, the Investor will receive certain additional
information regarding the Offering, including pricing information (the “Offering Information”). Such
information may be provided to the Investor by any means permitted under the
Act, including the Prospectus Supplement, a free writing prospectus and oral
communications.

     

    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
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 the
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 Offering Information and this
Agreement is accepted and countersigned by or on behalf of the
Company.

     

    10.        The
Company acknowledges that the only material, non-public information relating to
the Company it has provided to the Investor in connection with the Offering
prior to the date hereof is the existence of the Offering.

     

     

    


     

    [Signature Page
Follows]

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    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:  April __, 2010
	 	 	
               

               

            
	 	INVESTOR	
               

               

            
	 	By:	 
	 	Print
Name:	
               

            
	 	Title:	
               

            
	 	Address:	
               

            
	 	 	
               

            


    

     

    


    


     

    


    


    Agreed
and Accepted

    this ___
day of April, 2010:

    


     

    ASPENBIO
PHARMA, INC.

     

    


    By:  _______________________________                                                         

    Title:

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    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 Agent.

     

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

     

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

    


    2.3           Investor
acknowledges that the Company has agreed to pay Lazard Capital Markets LLC
(“LCM” or the “Placement Agent”) a fee of six
and one-half percent (6.5%) (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 the date hereof (the
“Placement Agreement”),
with the Placement Agent that contains certain representations, warranties,
covenants and agreements of the Company that may be relied upon by the Investor,
which shall be a third party beneficiary thereof.  The Company
understands and confirms that the Investor will rely on the such representations
and warranties and covenants set forth in the Placement Agent Agreement and
herein in effecting transactions in securities of the Company.  All of
the disclosure furnished by or on behalf of the Company to the Investor
regarding the Company, its business and the transactions contemplated hereby,
including the Disclosure Package and the Offering Information, is true and
correct in all material respects and does not contain any untrue statement of a
material fact or omit to state any material fact necessary in order to make the
statements made therein, in light of the circumstances under which they were
made, not misleading.

    


    2.5           The
Company covenants and agrees to use its best efforts to keep the Registration
Statement effective until the earlier of (x) such time as all of the Shares and
Warrant Shares issued or issuable can be sold by the Investor or its affiliates
immediately without compliance with the registration requirements of the Act
pursuant to Rule 144 under the Act and (y) the date all of the Shares and
Warrant Shares issued or issuable shall have been sold by the Investor and its
affiliates.

    


    3.           Closing
and Delivery of the Shares, Warrants 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
Obligations of the Parties.

    


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

    


    (b)           Conditions
to the Investor’s Obligations.  The Investor’s
obligation to purchase the Units will be subject to (x) the representations and
warranties made by the Company in the Agreements and the Placement Agreement
shall be true and correct in all material respects (other than such
representations and warranties qualified by materiality or material adverse
effect, which representations and warranties shall be true and correct in all
respects) as of the date hereof and as of the Closing Date and the Company shall
have fulfilled those undertakings of the Company required to be fulfilled prior
to the Closing Date, including without limitation, those contained in the
Placement Agreement, and (y) that the Placement Agent shall not have: (i)
terminated the Placement Agreement pursuant to the terms thereof or (ii)
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.  The Investor
understands and agrees that, in the event that LCM in its sole discretion
determines that the conditions to closing in the Placement Agreement have not
been satisfied or if the Placement Agreement may be terminated for any other
reason permitted by such Agreement, then LCM may, but shall not be obligated to,
terminate such Agreement, which shall have the effect of terminating this
Subscription Agreement pursuant to Section 14
below.

    


    3.3           Delivery
of Funds.

    


    Delivery Versus Payment
through The Depository Trust Company.  If the Investor elects
to settle the Shares 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.

     

     

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    3.4           Delivery
of Shares.

    


    Delivery Versus Payment
through The Depository Trust Company.  If the Investor elects
to settle the Shares 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 Agent (as to
itself), that:

    


    4.1           The
Investor (a) is knowledgeable, sophisticated and experienced in making, and is
qualified to make decisions with respect to, investments in shares 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 and the documents
incorporated by reference therein and the Offering Information.

    


    4.2           The
Investor acknowledges that (a) No action has been or will be taken in any
jurisdiction outside the United States by the Company or the Placement Agent
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 Agent is 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 or
incorporated by reference in the Base Prospectus, the Prospectus Supplement or
any free writing prospectus.

     

    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, the Offering Information 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 and made such investigation as it, in its sole discretion,
has deemed necessary or appropriate in connection with its purchase of the
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 Agent first contacted the Investor about the
Offering, the Investor has not disclosed any information regarding the Offering
to any third parties (other than its legal, accounting and other advisors) and
has not engaged in any purchases or sales involving the securities of the
Company (including, without limitation, any Short Sales involving the Company’s
securities).  The Investor covenants that it will not engage in any
purchases or sales in the securities of the Company (including Short Sales)
prior to the time that the transactions contemplated by this Agreement are
publicly disclosed.  The 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 (but shall not be deemed to include the location
and/or reservation of borrowable shares of Common Stock).

     

    5.           Survival of Representations,
Warranties and Agreements; Third Party
Beneficiary.  Notwithstanding any investigation made by any
party to this Agreement or by the Placement Agent, all covenants, agreements,
representations and warranties made by the Company and the Investor herein will
survive the execution of this Agreement, the delivery to the Investor of the
Shares and Warrants being purchased and the payment therefor.  The
Placement Agent 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 (c) 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 electronic confirmation of receipt and
will be delivered and addressed as follows:

     

     

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              (a)      
      

            	
              if to the Company,
      to:

            


    

     

    AspenBio
Pharma, Inc.

    1585
South Perry Street

    Castle
Rock, CO 80104

    Attention:  Jeff
McGonegal, Chief Financial Officer

    Facsimile:  303-798-8332

    


    with copies
to:

     

    Ballard
Spahr LLP

    1735
Market street, 51st
Floor

    Philadelphia,
PA 19103

    Attention:  Mary
J. Mullany, Esq.

    Facsimile:  215-665-8500

     

    
      
      

      
        	
                (b)      
      

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

              


      

       

    

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

     

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

     

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

     

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

     

    11.         Counterparts.  This
Agreement may be executed in two or more counterparts, each of which will
constitute an original, but all of which, when taken together, will constitute
but one instrument, and will become effective when one or more counterparts have
been signed by each party hereto and delivered to the other
parties.  The Company and the Investor acknowledge and agree that the
Company shall deliver its counterpart to the Investor along with the Prospectus
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 signed 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, prior to the opening of
the financial markets in New York City on the business day immediately after the
date hereof, (a) issue a press release announcing the Offering and disclosing
all material information regarding the Offering and (b) file a Current Report on
Form 8-K with the Securities and Exchange Commission including a form of this
Agreement and a form of Warrant as exhibits thereto.  Notwithstanding
the foregoing, the Company shall not publicly disclose the name of the Investor
or any affiliate or investment adviser of the Investor, or include the name of
the Investor or any affiliate or investment adviser of any Investor in any press
release or filing with the Securities and Exchange Commission or any regulatory
agency or trading market, without the prior written consent of such Investor,
except (i) as required by federal securities law and (ii) to the extent such
disclosure is required by law or trading market regulations, in which case the
Company shall provide the Investor with prior written notice of such disclosure
permitted under this sub-clause (ii).  From and after the issuance of
the press release described above, the Investor shall not be in possession of
any material, non-public information received from the Company or any of its
officers, directors or employees.

     

    14.           Termination.  In the
event that the Placement Agreement is terminated by the Placement Agent pursuant
to the terms thereof, this Agreement shall terminate without any further action
on the part of the parties hereto.

     

     

     

     

     

     

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Exhibit
A

     

    ASPENBIO
PHARMA, 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: