ex10-1.htm



NONE OF THE SECURITIES TO WHICH THIS PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT (THE "SUBSCRIPTION AGREEMENT") RELATES HAVE BEEN REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE "1933 ACT"), OR ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD IN THE UNITED STATES OR TO U.S. PERSONS (AS DEFINED HEREIN) EXCEPT PURSUANT TO AN EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.


 


DEBT SETTLEMENT AND SUBSCRIPTION AGREEMENT


 


THIS DEBT SETTLEMENT AND SUBSCRIPTION AGREEMENT (the "Agreement") made as of the _____ of February, 2011.


 



	
BETWEEN:

	
INTELIMAX MEDIA INC. (the "Company")







 



	
AND:

	
_____________________ (the "Subscriber")







 


WHEREAS:


 



	
A.

	
The Subscriber wishes to subscribe for ________________ units in the capital stock of our Company (the “Units”), at a deemed price of $0.20 per Unit, for an aggregate cost of $____________________ (the “Subscription Proceeds”) with each Unit being comprised of a share of the Company’s common stock and a warrant to acquire another share of the company’s common stock at $0.30 per share (the “Warrant”);







 



	
B.

	
The Company is indebted to the Subscriber in the amount of $__________________ (the "Outstanding Amount”);







 



	
C.

	
In lieu of receiving cash as payment of the Outstanding Amount, the Subscriber has agreed to accept the Units as payment of the Outstanding Amount pursuant to the terms and conditions set forth in this Agreement; and







 



	
D.

	
In lieu of receiving cash in payment of the Subscription Proceeds, the Company is willing to apply the Outstanding Amount in payment of the Subscription Proceeds.







 


NOW THEREFORE THIS AGREEMENT witnesses that, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties hereto agree as follows:


 



1.  Interpretation




 




	
1.1

	
In this Agreement, words importing the singular number only shall include the plural and vice versa, words importing gender shall include all genders and words importing persons shall include individuals, corporations, partnerships, associations, trusts, unincorporated organizations, governmental bodies and other legal or business entities of any kind whatsoever.









 



	
1.2

	
Any reference to currency is to the currency of the United States of America unless otherwise indicated.







 



	
1.3

	
The Warrant is more fully described in Schedule D to this Agreement.







 




  





1











  







 


2.  Acknowledgement of Indebtedness




 



	
2.1

	
The Company and the Subscriber acknowledge and agree that the Company is indebted to the Subscriber in the amount of the Outstanding Amount.







 



3.  Payment of Indebtedness




 



	
3.1

	
As full and final payment of the Outstanding Amount to the Subscriber, and as payment of the Subscription Proceeds to the Company, the Company will on the Closing Date (as defined herein) issue to the Subscriber the Units, as fully paid and non-assessable, and the Subscriber will accept the Units as full and final payment of the Outstanding Amount.







 



4.  Release




 




	
4.1

	
The Subscriber hereby agrees that upon delivery of the Units by the Company in accordance with the provisions of this Agreement, the Outstanding Amounts will be fully satisfied and extinguished, and the Subscriber will remise, release and forever discharge the Company and its respective directors, officers, employees, successors, solicitors, agents and assigns from any and all obligations relating to the Outstanding Amounts.









 



5.  Documents Required from Subscriber




 



	
5.1

	
The Subscriber must complete, sign and return to the Company an executed copy of this Agreement.







 



	
5.2

	
The Subscriber must complete, sign and return to the Company an executed copy of Schedule A to this Agreement.







 



	
5.3

	
The Subscriber must complete, sign and return to the Company an executed copy of Schedule B to this Agreement.







 



	
5.4

	
The Subscriber must complete, sign and return to the Company an executed copy of Schedule C to this Agreement.







 



	
5.5

	
The Subscriber shall complete, sign and return to the Company as soon as possible, on request by the Company, any documents, questionnaires, notices and undertakings as may be required by regulatory authorities, stock exchanges and applicable law.







 



6.  Closing




 



	
6.1

	
Closing of the offering of the Units (the "Closing") shall occur on or before March 1, 2011, or on such other date as may be determined by the Company (the "Closing Date").







 



7.  Acknowledgements of Subscriber




 




	
7.1

	
The Subscriber acknowledges:









 



	
(a)  

	
no agency, governmental authority, regulatory body, stock exchange or other entity has made any finding or determination as to the merit for investment of, nor have any such agencies or governmental authorities, regulatory bodies, stock exchanges or other entities made any recommendation or endorsement with respect to, the Units;







 



	
(b)  

	
the sale and delivery of the Units is conditional upon such sale being exempt from the prospectus filing and registration requirements, and being exempt from the requirement to deliver an offering memorandum in connection with the distribution of the Units under the applicable securities laws or upon the issuance of such orders, consents or approvals as may be required to permit such sale without the requirement of filing a prospectus or registration statement;







 




  





2











  






 



	
(c)  

	
none of the Units have been or will be registered under the 1933 Act or the securities laws of any state and the Units may not be offered or sold, directly or indirectly, in the United States to, or for the account or benefit of, a U.S. Person or a person in the United States unless registered under the 1933 Act and the securities laws of all applicable states or unless an exemption from such registration requirements is available, and the Company has no obligation or present intention of filing a registration statement under the U.S. Securities Act in respect of any of the Units ;







 



	
(d)  

	
the Subscriber may not offer, sell or transfer the Units within the United States or to, or for the account or benefit of, a U.S. Person, unless the Units are registered under the 1933 Act and the securities laws of all applicable states or an exemption from such registration requirements is available;







 



	
(e)  

	
the acquisition of the Units  has not been made through or as a result of any “general solicitation or general advertising” (as such terms are used in Rule 502(c) of Regulation D) the distribution of the Units has not been accompanied by any advertisement, including, without limitation, in printed public media, radio, television or telecommunications, including electronic display, or as part of a general solicitation;







 



	
(f)  

	
the certificates evidencing the Units will bear a legend regarding restrictions on transfer as required pursuant to applicable Securities Laws, including applicable federal and state securities laws of the United States;







 



	
(g)  

	
the Subscriber and the Subscriber's advisor(s) have had a reasonable opportunity to ask questions of and receive answers from the Company regarding the Offering, and to obtain additional information, to the extent possessed or obtainable without unreasonable effort or expense, necessary to verify the accuracy of the information contained in the Company Information, or any business plan, corporate profile or any other document provided to the Subscriber;







 



	
(h)  

	
the books and records of the Company were available upon reasonable notice for inspection, subject to certain confidentiality restrictions, by the Subscriber during reasonable business hours at its principal place of business and that all documents, records and books pertaining to this Offering have been made available for inspection by the Subscriber, the Subscriber's attorney and/or advisor(s);







 



	
(a)  

	
the Subscriber will indemnify and hold harmless the Company and, where applicable, its respective 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 Subscriber contained herein, the Agreement or in any other document furnished by the Subscriber to the Company in connection herewith, being untrue in any material respect or any breach or failure by the Subscriber to comply with any covenant or agreement made by the Subscriber to the Company in connection therewith;







 



	
(b)  

	
neither the SEC nor any other securities commission or similar regulatory authority has reviewed or passed on the merits of the Units ;







 



	
(c)  

	
no documents in connection with this Offering have been reviewed by the SEC or any state securities administrators;







 



	
(i)  

	
there is no government or other insurance covering any of the Units ;







 



	
(j)  

	
the Company is relying on an exemption from the requirements to provide the Subscriber with a prospectus or registration statement and to sell securities through a person or company registered to sell securities under the securities laws or other applicable securities legislation and, as a consequence of acquiring Shares pursuant to this exemption, certain protections, rights and remedies provided by the securities laws or other applicable securities legislation including statutory rights of rescission or damages, will not be available to the Subscriber; and







 




  





3











  






 



	
(k)  

	
no person has made to the Subscriber any written or oral representations:







 



	
(i)  

	
that any person will resell or repurchase the Units;







 



	
(ii)  

	
that any person will refund the purchase price of the Units; or







 



	
(iii)  

	
as to the future price or value of any of the Units.







 



8.  Representations, Warranties and Covenants of the Subscriber




 



	
8.1

	
The Subscriber hereby represents and warrants to the Company (which representations and warranties shall survive the Closing) that:







 



	
(a)  

	
the Subscriber is resident in the United States;







 



	
(b)  

	
the Subscriber has received and carefully read this Agreement;







 



	
(c)  

	
the Subscriber has the legal capacity and competence to enter into and execute this Subscription Agreement and to take all actions required pursuant hereto and, if the Subscriber is a corporation, it is duly incorporated and validly subsisting under the laws of its jurisdiction of incorporation and all necessary approvals by its directors, shareholders and others have been obtained to authorize execution and performance of this Subscription Agreement on behalf of the Subscriber;







 



	
(d)  

	
the Subscriber (i) has adequate net worth and means of providing for its current financial needs and possible personal contingencies, (ii) has no need for liquidity in this investment, and (iii) is able to bear the economic risks of an investment in the Units for an indefinite period of time, and can afford the complete loss of such investment;







 



	
(e)  

	
the Subscriber is aware that an investment in the Company is speculative and involves certain risks, including the possible loss of the investment;







 



	
(f)  

	
the entering into of this Subscription Agreement and the transactions contemplated hereby do not result in the violation of any of the terms and provisions of any law applicable to, or, if applicable, the constating documents of, the Subscriber, or of any agreement, written or oral, to which the Subscriber may be a party or by which the Subscriber is or may be bound;







 



	
(g)  

	
the Subscriber has duly executed and delivered this Subscription Agreement and it constitutes a valid and binding agreement of the Subscriber enforceable against the Subscriber;







 



	
(h)  

	
the Subscriber has the requisite knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of the investment in the Units and the Company, and the Subscriber is providing evidence of such knowledge and experience in these matters through the information requested in the Agreement;







 



	
(i)  

	
the Subscriber understands and agrees that the Company and others will rely upon the truth and accuracy of the acknowledgements, representations and agreements contained in this Subscription Agreement, and agrees that if any of such acknowledgements, representations and agreements are no longer accurate or have been breached, the Subscriber shall promptly notify the Company;







 



	
(j)  

	
all information contained in the Agreement is complete and accurate and may be relied upon by the Company, and the Subscriber will notify the Company immediately of any material change in any such information occurring prior to the closing of the purchase of the Units ;







 




  





4











  






 



	
(k)  

	
the Subscriber is purchasing the Units for its own account for investment purposes only and not for the account of any other person and not for distribution, assignment or resale to others, and no other person has a direct or indirect beneficial interest is such Shares, and the Subscriber has not subdivided his interest in the Units with any other person;







 



	
(l)  

	
the Subscriber is not an underwriter of, or dealer in, the common shares of the Company, nor is the Subscriber participating, pursuant to a contractual agreement or otherwise, in the distribution of the Units ;







 



	
(m)  

	
the Subscriber has made an independent examination and investigation of an investment in the Units and the Company and has depended on the advice of its legal and financial advisors and agrees that the Company will not be responsible in anyway whatsoever for the Subscriber's decision to invest in the Units and the Company;







 



	
(n)  

	
if the Subscriber is acquiring the Units as a fiduciary or agent for one or more investor accounts, the investor accounts for which the Subscriber acts as a fiduciary or agent satisfy the definition of an "Accredited Investor", as the term is defined under Regulation D of the 1933 Act;







 



	
(o)  

	
if the Subscriber is acquiring the Units as a fiduciary or agent for one or more investor accounts, the Subscriber has sole investment discretion with respect to each such account, and the Subscriber has full power to make the foregoing acknowledgements, representations and agreements on behalf of such account;







 



	
(p)  

	
the Subscriber is not aware of any advertisement of any of the Units and is not acquiring the Units as a result of any form of general solicitation or general advertising including advertisements, articles, notices or other communications published in any newspaper, magazine or similar media or broadcast over radio or television, or any seminar or meeting whose attendees have been invited by general solicitation or general advertising; and







 



	
(q)  

	
no person has made to the Subscriber any written or oral representations:







 



	
(i)  

	
that any person will resell or repurchase any of the Units ;







 



	
(ii)  

	
that any person will refund the purchase price of any of the Units ;







 



	
(iii)  

	
as to the future price or value of any of the Units; or







 



	
(iv)  

	
that any of the Units will be listed and posted for trading on any stock exchange or automated dealer quotation system or that application has been made to list and post any of the Units of the Company on any stock exchange or automated dealer quotation system.







 



	
8.2

	
The Subscriber hereby covenants with the Company (which covenants shall survive the Closing) that:







 



	
(a)  

	
the Subscriber understands and agrees not to engage in any hedging transactions involving any of the Units unless such transactions are in compliance with the provisions of the 1933 Act and in each case only in accordance with applicable state and provincial securities laws;







 



	
(b)  

	
the Subscriber will indemnify and hold harmless the Company and, where applicable, its respective 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 Subscriber contained herein or in any document furnished by the Subscriber to the Company in connection herewith being untrue in any material respect or any breach or failure by the Subscriber to comply with any covenant or agreement made by the Subscriber to the Company in connection therewith; and







 



	
(c)  

	
the Subscriber will not offer or sell any of the Units in the United States or, directly or indirectly, to U.S. Persons except in accordance with the provisions of Regulation S, pursuant to an effective registration statement under the 1933 Act, or pursuant to an exemption from, or in a transaction not subject to, the registration requirements of the 1933 Act and in each case only in accordance with applicable state and provincial securities laws.







 



	
8.3

	
In this Agreement, the term "U.S. Person" shall have the meaning ascribed thereto in Regulation S.







 




  





5











  






 


9.  Representations and Warranties will be Relied Upon by the Company


 


9.1 The Subscriber acknowledges that the representations and warranties contained herein are made by it with the intention that such representations and warranties may be relied upon by the Company and its legal counsel in determining the Subscriber's eligibility to purchase the Units under applicable securities legislation, or (if applicable) the eligibility of others on whose behalf it is contracting hereunder to purchase the Units under applicable securities legislation.  The Subscriber further agrees that by accepting delivery of the certificates representing the Units on the Closing Date, it will be representing and warranting that the representations and warranties contained herein are true and correct as at the Closing Date with the same force and effect as if they had been made by the Subscriber on the Closing Date and that they will survive the purchase by the Subscriber of Shares and will continue in full force and effect notwithstanding any subsequent disposition by the Subscriber of such Shares.


 



10.  Resale Restrictions




 




	
10.1

	
The Subscriber acknowledges that any resale of the Units will be subject to resale restrictions contained in the securities legislation applicable to each Subscriber or proposed transferee.  The Subscriber acknowledges that the Units have not been registered under the 1933 Act of the securities laws of any state of the United States.  The Units may not be offered or sold in the United States unless registered in accordance with United States federal securities laws and all applicable state and provincial securities laws or exemptions from such registration requirements are available.









 



	
10.2

	
The Subscriber acknowledges that restrictions on the transfer, sale or other subsequent disposition of the Units by the Subscriber may be imposed by securities laws in addition to any restrictions referred to in Section 10.1 above.







 



11.  Acknowledgement and Waiver




 



	
11.1

	
The Subscriber has acknowledged that the decision to purchase the Units was solely made on the basis of publicly available information.  The Subscriber hereby waives, to the fullest extent permitted by law, any rights of withdrawal, rescission or compensation for damages to which the Subscriber might be entitled in connection with the distribution of any of the Units.







 



12.  Legending and Registration of Subject Shares




 



	
12.1

	
The Subscriber hereby acknowledges that a legend may be placed on the certificates representing any of the Units to the effect that the Units represented by such certificates are subject to a hold period and may not be traded until the expiry of such hold period except as permitted by applicable securities legislation.







 



	
12.2

	
The Subscriber hereby acknowledges and agrees to the Company making a notation on its records or giving instructions to the registrar and transfer agent of the Company in order to implement the restrictions on transfer set forth and described in this Agreement.







 



13.  Costs




 



	
13.1

	
The Subscriber acknowledges and agrees that all costs and expenses incurred by the Subscriber (including any fees and disbursements of any special counsel retained by the Subscriber) relating to the purchase of the Units shall be borne by the Subscriber.







 



14.  Governing Law




 



	
14.1

	
This Agreement is governed by the laws of the Province of British Columbia and the laws of the Province of British Columbia applicable therein.







 



15.  Survival




 



	
15.1

	
This Agreement, including without limitation the representations, warranties and covenants contained herein, shall survive and continue in full force and effect and be binding upon the parties hereto notwithstanding the completion of the purchase of the Units by the Subscriber.







 




  





6











  






 


16.  Assignment


 



	
16.1

	
This Agreement is not transferable or assignable.







 




17. Execution






 



	
17.1

	
The Company shall be entitled to rely on delivery by facsimile machine of an executed copy of this Agreement and acceptance by the Company of such facsimile copy shall be equally effective to create a valid and binding agreement between the Subscriber and the Company in accordance with the terms hereof.







 



18.  Severability




 



	
18.1

	
The invalidity or unenforceability of any particular provision of this Agreement shall not affect or limit the validity or enforceability of the remaining provisions of this Agreement.







 



19.  Entire Agreement




 



	
19.1

	
Except as expressly provided in this Agreement and in the agreements, instruments and other documents contemplated or provided for herein, this Agreement contains the entire agreement between the parties with respect to the sale of the Units and there are no other terms, conditions, representations or warranties, whether expressed, implied, oral or written, by statute or common law, by the Company or by anyone else.







 



20.  Notices




 



	
20.1

	
All notices and other communications hereunder shall be in writing and shall be deemed to have been duly given if mailed or transmitted by any standard form of telecommunication.  Notices to the Subscriber shall be directed to the address on the signature page of this Agreement and notices to the Company shall be directed to it at Suite 2320, 555 W. Hastings Street, Vancouver, BC, V6B 4N4, Attention the President, telephone number (604) 742-1111.







 



21.  Counterparts




 



	
21.1

	
This Agreement may be executed in any number of counterparts, each of which, when so executed and delivered, shall constitute an original and all of which together shall constitute one instrument.














  





7











  






 


SCHEDULE A


 


TO:  INTELIMAX MEDIA INC. (the “Issuer”) SUITE 2320, 555 W. HASTINGS STREET, VANCOUVER, BC, V6B 4N4


 



	
____________________Units


	
US$____________


	
The Subscriber owns, directly or indirectly, the following securities of the Issuer:


	  
	
[Check if applicable]  The Subscriber is  o an affiliate of the Issuer or o a member of the professional group







 


The Subscriber directs the Issuer to issue, register and deliver the certificates representing the Units as follows:


 



	
REGISTRATION INSTRUCTIONS

	  	
DELIVERY INSTRUCTIONS


	  	  	  
	
Name to appear on certificate

	  	
Name and account reference, if applicable


	  	  	  
	
Account reference if applicable

	  	
Contact name


	  	  	  
	
Address

	  	
Address


	  	  	  
	  	  	
Telephone Number







 


EXECUTED by the Subscriber this _______ day of _____________, 2011.  By executing this Subscription Agreement, the Subscriber certifies that the Subscriber and any beneficial purchaser for whom the Subscriber is acting is resident in the jurisdiction shown as the “Address of Purchaser”.


 



	
WITNESS:

	  	
EXECUTION BY SUBSCRIBER:


	  	  	
X


	
Signature of Witness

	  	
Signature of individual (if Subscriber is an individual)


	  	  	
X


	
Name of Witness

	  	
Authorized signatory (if Subscriber is not an individual)


	  	  	  
	
Address of Witness

	  	
Name of Subscriber (please print)


	  	  	  
	  	  	
Name of authorized signatory (please print)


	
Accepted this _____ day of ____________, 2010

	  	  
	
INTELIMAX MEDIA INC.

	  	
Address of Subscriber (residence)


	
Per:

	  	  
	  	  	
*Telephone Number


	
Authorized Signatory

	  	  
	  	  	
*E-mail address


	  	  	  
	  	  	
*Social Security/Insurance No./Gov ID No.:












*Required from all Subscribers


 




  





8











  






 


SCHEDULE B


 


UNITED STATES


ACCREDITED INVESTOR QUESTIONNAIRE


 


All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the Subscription Agreement.


 


This Questionnaire is for use by each Subscriber who is a US person (as that term is defined Regulation S of the United States Securities Act of 1933 (the “1933 Act”)) and has indicated an interest in purchasing Shares of the Issuer.  The purpose of this Questionnaire is to assure the Issuer that each Subscriber will meet the standards imposed by the 1933 Act and the appropriate exemptions of applicable state securities laws.  The Issuer will rely on the information contained in this Questionnaire for the purposes of such determination.  The Securities will not be registered under the 1933 Act in reliance upon the exemption from registration afforded by Section 3(b) and/or Section 4(2) and Regulation D of the 1933 Act.  This Questionnaire is not an offer of the Securities or any other securities of the Issuer in any state other than those specifically authorized by the Issuer.


 


All information contained in this Questionnaire will be treated as confidential.  However, by signing and returning this Questionnaire, each Subscriber agrees that, if necessary, this Questionnaire may be presented to such parties as the Issuer deems appropriate to establish the availability, under the 1933 Act or applicable state securities law, of exemption from registration in connection with the sale of the Securities hereunder.


 


The Subscriber covenants, represents and warrants to the Issuer that it satisfies one or more of the categories of “Accredited Investors”, as defined by Regulation D promulgated under the 1933 Act, as indicated below:  (Please initial in the space provide those categories, if any, of an “Accredited Investor” which the Subscriber satisfies.)


 





	
Category 1

	
An organization described in Section 501(c)(3) of the United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the specific purpose of acquiring the Securities, with total assets in excess of US $5,000,000.











 



	
Category 2

	
A natural person whose individual net worth, or joint net worth with that person’s spouse, and exclusive of the person’s residence, on the date of purchase exceeds US $1,000,000.







 




	
Category 3

	
A natural person who had an individual income in excess of US $200,000 in each of the two most recent years or joint income with that person’s spouse in excess of US $360,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.









 




  





9











  






 




	
Category 4

	
A “bank” as defined under Section (3)(a)(2) of the 1933 Act or savings and loan association or other institution as defined in Section 3(a)(5)(A) of the 1933 Act acting in its individual or fiduciary capacity; a broker dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934 (United States); an insurance company as defined in Section 2(13) of the 1933 Act; an investment company registered under the Investment Company Act of 1940 (United States) or a business development company as defined in Section 2(a)(48) of such Act; a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 361(c) or (d) of the Small Business Investment Act of 1958 (United States); a plan with total assets in excess of $5,000,000 established and maintained by a state, a political subdivision thereof, or an agency or instrumentality of a state or a political subdivision thereof, for the benefit of its employees; an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 (United States) whose investment decisions are made by a plan fiduciary, as defined in Section 3(21) of 



such Act, which is either a bank, savings and loan association, insurance company or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000, or, if a self-directed plan, whose investment decisions are made solely by persons that are accredited investors.









 



	
Category 5

	
A private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940 (United States).







 



	
Category 6

	
A director or executive officer of the Issuer.







 




	
Category 7

	
A trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Securities, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) under the 1933 Act.









 




	
Category 8

	
An entity in which all of the equity owners satisfy the requirements of one or more of the foregoing categories.









 


Note that prospective Subscriber claiming to satisfy one of the above categories of Accredited Investor may be required to supply the Issuer with a balance sheet, prior years’ federal income tax returns or other appropriate documentation to verify and substantiate the Subscriber’s status as an Accredited Investor.


 


If the Subscriber is an entity which initialled Category 8 in reliance upon the Accredited Investor categories above, state the name, address, total personal income from all sources for the previous calendar year, and the net worth (exclusive of home, home furnishings and personal automobiles) for each equity owner of the said entity:











 


The Subscriber hereby certifies that the information contained in this Questionnaire is complete and accurate and the Subscriber will notify the Issuer promptly of any change in any such information.  If this Questionnaire is being completed on behalf of a corporation, partnership, trust or estate, the person executing on behalf of the Subscriber represents that it has the authority to execute and deliver this Questionnaire on behalf of such entity.


 


IN WITNESS WHEREOF, the undersigned has executed this Questionnaire as of the ___ day of _______________, 2011.


 



	
If a Corporation, Partnership or Other Entity:

	
If an Individual:


	
________________________________________


Print of Type Name of Entity


________________________________________


Signature of Authorized Signatory


________________________________________


Type of Entity

	
____________________________________


Signature


____________________________________


Print or Type Name


 


 







 




  





10











  






 


SCHEDULE C


 


CANADIAN


45-106 INVESTOR QUESTIONNAIRE


 


All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the  Agreement.


 


The purpose of this Questionnaire is to assure the Company that the Subscriber will meet certain requirements of National Instrument 45-106 ("NI 45-106").  The Company will rely on the information contained in this Questionnaire for the purposes of such determination.


 


The Subscriber covenants, represents and warrants to the Company that:


 




	
1.

	
the Subscriber has such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of the transactions detailed in the Subscription Agreement and the Subscriber is able to bear the economic risk of loss arising from such transactions;









 




	
2.

	
the Subscriber is (tick one or more of the following boxes):







 





	
(A)

	
a director, executive officer, employee or control person of the Company or an affiliate of the Company

	  o
	
(B)

	
a spouse, parent, grandparent, brother, sister or child of a director, executive officer, founder or control person of the Company or an affiliate of the Company

	  o
	
(C)

	
a parent, grandparent, brother, sister or child of the spouse of a director, executive officer, founder or control person of the Company or an affiliate of the Company

	  o
	
(D)

	
a close personal friend of a director, executive officer, founder or control person of the Company

	  o
	
(E)

	
a close business associate of a director, executive officer, founder or control person of the Company or an affiliate of the Company

	  o
	
(F)

	
an accredited investor

	  o
	
(G)

	
a company, partnership or other entity of which a majority of the voting securities are beneficially owned by, or a majority of the directors are, persons described in paragraphs A to F

	  o
	
(H)

	
a trust or estate of which all of the beneficiaries or a majority of the trustees or executors are persons described in paragraphs A to F

	  o
	
(I)

	
purchasing as principal Securities with an aggregate acquisition cost of not less than CDN$150,000

	  o





 




	
3.

	
if the Subscriber has checked box B, C, D, E, G or H in Section 2 above, the director, executive officer, founder or control person of the Company with whom the undersigned has the relationship is:









 


_______________________________________________________________________________


 


(Instructions to Subscriber: fill in the name of each director, executive officer, founder and control person which you have the above-mentioned relationship with.  If you have checked box G or H, also indicate which of A to F describes the securityholders, directors, trustees or beneficiaries which qualify you as box G or H and provide the names of those individuals.  Please attach a separate page if necessary).


 




	
4.

	
if the Subscriber is resident in Ontario, the Subscriber is (tick one or more of the following boxes):









 



	
(A)

	
a founder of the Company

	  o
	
(B)

	
an affiliate of a founder of the Company

	  o
	
(C)

	
a spouse, parent, brother, sister, grandparent or child of a director, executive officer or founder of the Company

	  o
	
(D)

	
a person that is a control person of the Company

	  o
	
(E)

	
an accredited investor

	  o
	
(F)

	
purchasing as principal Securities with an aggregate acquisition cost of not less than CDN$150,000

	  o





 




	
5.

	
if the Subscriber has checked box A, B, C or D in Section 4 above, the director, executive officer, founder or control person of the Company with whom the undersigned has the relationship is:









 


_______________________________________________________________________________


 


(Instructions to Subscriber: fill in the name of each director, executive officer, founder, affiliate and control person which you have the above-mentioned relationship with.)


 




  





11











  






 




	
6.

	
if the Subscriber has ticked box F in Section 2 or box E in Section 4 above, the Subscriber satisfies one or more of the categories of "accredited investor" (as that term is defined in NI 45-106) indicated below (please check the appropriate box):









 








	
o

	
(a)   a Canadian financial institution as defined in National Instrument 14-101, or an authorized foreign bank listed in Schedule III of theBank Act (Canada);

















 






	
o

	
(b)   the Business Development Bank of Canada incorporated under theBusiness Development Bank Act (Canada);













 





	
o

	
(c)   a subsidiary of any person referred to in any of the foregoing categories, if the person owns all of the voting securities of the subsidiary, except the voting securities required by law to be owned by directors of that subsidiary;











 





	
o

	
(d)   an individual registered or formerly registered under securities legislation in a jurisdiction of Canada, as a representative of a person or company registered under securities legislation in a jurisdiction of Canada, as an adviser or dealer, other than a limited market dealer registered under theSecurities Act (Ontario) or the Securities Act (Newfoundland);











 





	
o

	
(e)   an individual registered or formerly registered under the securities legislation of a jurisdiction of Canada as a representative of a person referred to in paragraph (d);











 





	
o

	
(f)   the government of Canada or a province, or any crown corporation or agency of the government of Canada or a province;











 





	
o

	
(g)   a municipality, public board or commission in Canada and a metropolitan community, school board, the Comite de gestion de la taxe scholaire de l'ile de Montreal or an intermunicipal management board in Québec;











 





	
o

	
(h)   a national, federal, state, provincial, territorial or municipal government of or in any foreign jurisdiction, or any agency thereof;











 





	
o

	
(i)   a pension fund that is regulated by either the Office of the Superintendent of Financial Institutions (Canada) or a pension commission or similar regulatory authority of a jurisdiction of Canada;











 






	
o

	
(j)   an individual who either alone or with a spouse beneficially owns, directly or indirectly, financial assets (as defined in NI 45-106) having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds CDN$1,000,000;













 





	
o

	
(k)   an individual whose net income before taxes exceeded CDN$200,000 in each of the two more recent calendar years or whose net income before taxes combined with that of a spouse exceeded $300,000 in each of those years and who, in either case, reasonably expects to exceed that net income level in the current calendar year;











 





	
o

	
(l)   an individual who, either alone or with a spouse, has net assets of at least CDN $5,000,000;











 





	
o

	
(m)   a person, other than an individual or investment fund, that had net assets of at least CDN$5,000,000 as reflected on its most recently prepared financial statements;











 





	
o

	
(n)   an investment fund that distributes it securities only to persons that are accredited investors at the time of distribution, a person that acquires or acquired a minimum of CDN$150,000 of value in securities, or a person that acquires or acquired securities under Sections 2.18 or 2.19 of NI 45-106;











 




  





12











  






 





	
o

	
(o)   an investment fund that distributes or has distributed securities under a prospectus in a jurisdiction of Canada for which the regulator or, in Québec, the securities regulatory authority, has issued a receipt;











 





	
o

	
(p)   a trust company or trust corporation registered or authorized to carry on business under theTrust and Loan Companies Act (Canada) or under comparable legislation in a jurisdiction of Canada or a foreign jurisdiction, acting on behalf of a fully managed account managed by the trust company or trust corporation, as the case may be;











 





	
o

	
(q)   a person acting on behalf of a fully managed account managed by that person, if that person (i) is registered or authorized to carry on business as an adviser or the equivalent under the securities legislation of a jurisdiction of Canada or a foreign jurisdiction, and (ii) in Ontario, is purchasing a security that is not a security of an investment fund;











 





	
o

	
(r)   a registered charity under theIncome Tax Act (Canada) that, in regard to the trade, has obtained advice from an eligibility advisor or an advisor registered under the securities legislation of the jurisdiction of the registered charity to give advice on the securities being traded;











 





	
o

	
(s)   an entity organized in a foreign jurisdiction that is analogous to any of the entities referred to in paragraphs (a) to (d) or paragraph (i) in form and function;











 





	
o

	
(t)   a person in respect of which all of the owners of interests, direct, indirect or beneficial, except the voting securities required by law are persons or companies that are accredited investors;











 





	
o

	
(u)   an investment funds that is advised by a person registered as an advisor or a person that is exempt from registration as an advisor; or











 





	
o

	
(v)   a person that is recognized or designated by the securities regulatory authority or, except in Ontario and Québec, the regulator as (i) an accredited investor, or (ii) an exempt purchaser in Alberta or British Columbia after this instrument comes into force;











 


The Subscriber acknowledges and agrees that the Subscriber may be required by the Company to provide such additional documentation as may be reasonably required by the Company and its legal counsel in determining the Subscriber's eligibility to acquire the Securities under relevant legislation.


 


IN WITNESS WHEREOF, the undersigned has executed this Questionnaire as of the ________ day of __________________, 2011.


 




	
If an Individual:

	 	
If a Corporation, Partnership or Other Entity:


 


	
_________________________________


Signature

	 	
_________________________________________


Print or Type Name of Entity


	
 


_________________________________


Print or Type Name

	 	
 


_________________________________________


Signature of Authorized Signatory


	  	 	
 


__________________________________________


Type of Entity







 









 




  





13











  






 


SCHEDULE D


 


WARRANT CERTIFICATE







THESE SECURITIES HAVE NOT BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.







THESE WARRANTS WILL EXPIRE AND BECOME NULL AND VOID


AT 4:30 P.M. (BRITISH COLUMBIA TIME, TIME) ON FEBRUARY ___, 2011


 


SHARE PURCHASE WARRANTS


TO PURCHASE COMMON SHARES OF


INTELIMAX MEDIA INC.


 


incorporated in the Province of British Columbia


 


WARRANT CERTIFICATE


 


THIS IS TO CERTIFY THAT [NAME OF HOLDER] (the “Holder”), of [ADDRESS OF HOLDER], has the right to purchase, upon and subject to the terms and conditions hereinafter referred to, up to [NUMBER OF SHARES] fully paid and non-assessable common shares (the “Shares”) in the capital of Intelimax Media Inc. (hereinafter called the “Company”) on or before 4:30 p.m. (British Columbia Time time) on February ____, 2011 (the “Expiry Date”) at a price per Share (the “Exercise Price”) of US$0.30 on the terms and conditions attached hereto as Exhibit “A” (the “Terms and Conditions”).


 



	
  

	
1.

	
ONE (1) WARRANT AND THE EXERCISE PRICE ARE REQUIRED TO PURCHASE ONE SHARE.  THIS CERTIFICATE REPRESENTS [NUMBER OF WARRANTS] WARRANTS.







 



	
  

	
2.

	
These Warrants are issued subject to the Terms and Conditions, and the Warrant Holder may exercise the right to purchase Shares only in accordance with those Terms and Conditions.







 



	
  

	
3.

	
Nothing contained herein or in the Terms and Conditions will confer any right upon the Holder hereof or any other person to subscribe for or purchase any Shares at any time subsequent to the Expiry Date, and from and after such time, this Warrant and all rights hereunder will be void and of no value.







 


IN WITNESS WHEREOF the Company has executed this Warrant Certificate this ___ day of _______________, 2011.


 


INTELIMAX MEDIA INC.


 


 


Per:  


         


_________________________


Authorized Signatory


 




  





14











  






 


EXHIBIT “A”







TERMS AND CONDITIONS dated February ______, 2011, attached to the Warrants issued by Intelimax Media Inc.


 



1.  INTERPRETATION




 


1.1 Definitions


 


In these Terms and Conditions, unless there is something in the subject matter or context inconsistent therewith:


 



	
(a)  

	
“Company” means Intelimax Media Inc. until a successor corporation will have become such as a result of consolidation, amalgamation or merger with or into any other corporation or corporations, or as a result of the conveyance or transfer of all or substantially all of the properties and estates of the Company as an entirety to any other corporation and thereafter “Company” will mean such successor corporation;







 



	
(b)  

	
“Company’s Auditors” means an independent firm of accountants duly appointed as auditors of the Company;







 



	
(c)  

	
“Director” means a director of the Company for the time being, and reference, without more, to action by the directors means action by the directors of the Company as a Board, or whenever duly empowered, action by an executive committee of the Board;







 



	
(d)  

	
“herein”, “hereby” and similar expressions refer to these Terms and Conditions as the same may be amended or modified from time to time; and the expression “Article” and “Section,” followed by a number refer to the specified Article or Section of these Terms and Conditions;







 



	
(e)  

	
“person” means an individual, corporation, partnership, trustee or any unincorporated organization and words importing persons have a similar meaning;







 



	
(f)  

	
“shares” means the common shares in the capital of the Company as constituted at the date hereof and any shares resulting from any subdivision or consolidation of the shares;







 



	
(g)  

	
“Warrant Holders” or “Holders” means the holders of the Warrants; and







 



	
(h)  

	
“Warrants” means the warrants of the Company issued and presently authorized and for the time being outstanding.







 


1.2 Gender


 


Words importing the singular number include the plural and vice versa and words importing the masculine gender include the feminine and neuter genders.


 


1.3 Interpretation not affected by Headings


 


The division of these Terms and Conditions into Articles and Sections, and the insertion of headings are for convenience of reference only and will not affect the construction or interpretation thereof.


 


1.4 Applicable Law


 


The Warrants will be construed in accordance with the laws of the Province of British Columbia.


 




  





15











  







 


2.  ISSUE OF WARRANTS




 


2.1 Additional Warrants


 


The Company may at any time and from time to time issue additional warrants or grant options or similar rights to purchase shares of its capital stock.


 


2.2 Warrant to Rank Pari Passu


 


All Warrants and additional warrants, options or similar rights to purchase shares from time to time issued or granted by the Company, will rank pari passu whatever may be the actual dates of issue or grant thereof, or of the dates of the certificates by which they are evidenced.


 


2.3 Issue in substitution for Lost Warrants


 



	
(a)  

	
In case a Warrant becomes mutilated, lost, destroyed or stolen, the Company, at its discretion, may issue and deliver a new Warrant of like date and tenor as the one mutilated, lost, destroyed or stolen, in exchange for and in place of and upon cancellation of such mutilated Warrant, or in lieu of, and in substitution for such lost, destroyed or stolen Warrant and the substituted Warrant will be entitled to the benefit hereof and rank equally in accordance with its terms with all other Warrants issued or to be issued by the Company.







 



	
(b)  

	
The applicant for the issue of a new Warrant pursuant hereto will bear the cost of the issue thereof and in case of loss, destruction or theft furnish to the Company such evidence of ownership and of loss, destruction, or theft of the Warrant so lost, destroyed or stolen as will be satisfactory to the Company in its discretion and such applicant may also be required to furnish indemnity in amount and form satisfactory to the Company in its discretion, and will pay the reasonable charges of the Company in connection therewith.







 


2.4 Warrant Holder Not a Shareholder


 


The holding of a Warrant will not constitute the Holder thereof a shareholder of the Company, nor entitle him to any right or interest in respect thereof except as in the Warrant expressly provided.


 



3.  NOTICE




 


3.1 Notice to Warrant Holders


 


Any notice required or permitted to be given to the Holders will be in writing and may be given by prepaid registered post, electronic facsimile transmission or other means of electronic communication capable of producing a printed copy to the address of the Holder appearing on the Holder’s Warrant or to such other address as any Holder may specify by notice in writing to the Company, and any such notice will be deemed to have been given and received by the Holder to whom it was addressed if mailed, on the third day following the mailing thereof, if by facsimile or other electronic communication, on successful transmission, or, if delivered, on delivery; but if at the time or mailing or between the time of mailing and the third business day thereafter there is a strike, lockout, or other labour disturbance affecting postal service, then the notice will not be effectively given until actually delivered.


 


3.2 Notice to the Company


 


Any notice required or permitted to be given to the Company will be in writing and may be given by prepaid registered post, electronic facsimile transmission or other means of electronic communication capable of producing a printed copy to the address of the Company, and any such notice will be deemed to have been given and received by the Company to whom it was addressed if mailed, on the third day following the mailing thereof, if by facsimile or other electronic communication, on successful transmission, or, if delivered, on delivery; but if at the time or mailing or between the time of mailing and the third business day thereafter there is a strike, lockout, or other labour disturbance affecting postal service, then the notice will not be effectively given until actually delivered.


 




  





16











  







 


4.  EXERCISE OF WARRANTS




 




	
4.1

	
Method of Exercise of Warrants









 


The right to purchase shares conferred by the Warrants may be exercised by the Holder surrendering the Warrant Certificate representing same, with a duly completed and executed subscription in the form attached hereto and a bank draft or certified cheque payable to or to the order of the Company, at par, in Vancouver, Canada, for the purchase price applicable at the time of surrender in respect of the shares subscribed for in lawful money of the United States of America, to the Company at the address set forth in, or from time to time specified by the Company pursuant to, Section 3.2.


 



	
4.2

	
Effect of Exercise of Warrants







 



	
(a)  

	
Upon surrender and payment as aforesaid the shares so subscribed for will be deemed to have been issued and such person or persons will be deemed to have become the Holder or Holders of record of such shares on the date of such surrender and payment, and such shares will be issued at the subscription price in effect on the date of such surrender and payment.







 



	
(b)  

	
Within ten business days after surrender and payment as aforesaid, the Company will forthwith cause to be delivered to the person or persons in whose name or names the shares so subscribed for are to be issued as specified in such subscription or mailed to him or them at his or their respective addresses specified in such subscription, a certificate or certificates for the appropriate number of shares not exceeding those which the Warrant Holder is entitled to purchase pursuant to the Warrant surrendered.







 



	
4.3

	
Subscription for Less Than Entitlement







 


The Holder of any Warrant may subscribe for and purchase a number of shares less than the number which he is entitled to purchase pursuant to the surrendered Warrant. In the event of any purchase of a number of shares less than the number which can be purchased pursuant to a Warrant, the Holder thereof upon exercise thereof will in addition be entitled to receive a new Warrant in respect of the balance of the shares which he was entitled to purchase pursuant to the surrendered Warrant and which were not then purchased.


 



	
4.4

	
Warrants for Fractions of Shares







 


To the extent that the Holder of any Warrant is entitled to receive on the exercise or partial exercise thereof a fraction of a share, such right may be exercised in respect of such fraction only in combination with another Warrant or other Warrants which in the aggregate entitle the Holder to receive a whole number of such shares.


 



	
4.5

	
Expiration of Warrants







 


After the expiration of the period within which a Warrant is exercisable, all rights thereunder will wholly cease and terminate and such Warrant will be void and of no effect.


 



	
4.6

	
Time of Essence







 


Time will be of the essence hereof.


 



	
4.7

	
Subscription Price







 


Each Warrant is exercisable at a price per share (the “Exercise Price”) of US$0.30.  One (1) Warrant and the Exercise Price are required to subscribe for each share during the term of the Warrants.


 




  





17











  






 



	
4.8

	
Adjustment of Exercise Price







 



	
(a)  

	
The Exercise Price and the number of shares deliverable upon the exercise of the Warrants will be subject to adjustment in the event and in the manner following:







 



	
(i)  

	
If and whenever the shares at any time outstanding are subdivided into a greater or consolidated into a lesser number of shares the Exercise Price will be decreased or increased proportionately as the case may be; upon any such subdivision or consolidation the number of shares deliverable upon the exercise of the Warrants will be increased or decreased proportionately as the case may be.







 



	
(ii)  

	
In case of any capital reorganization or of any reclassification of the capital of the Company or in the case of the consolidation, merger or amalgamation of the Company with or into any other Company (hereinafter collectively referred to as a “Reorganization”), each Warrant will after such Reorganization confer the right to purchase the number of shares or other securities of the Company (or of the Company’s resulting from such Reorganization) which the Warrant Holder would have been entitled to upon Reorganization if the Warrant Holder had been a shareholder at the time of such Reorganization.







 


In any such case, if necessary, appropriate adjustments will be made in the application of the provisions of this Article Four relating to the rights and interest thereafter of the Holders of the Warrants so that the provisions of this Article Four will be made applicable as nearly as reasonably possible to any shares or other securities deliverable after the Reorganization on the exercise of the Warrants.


 


The subdivision or consolidation of shares at any time outstanding into a greater or lesser number of shares (whether with or without par value) will not be deemed to be a Reorganization for the purposes of this clause 4.8(a)(ii).


 



	
(b)  

	
The adjustments provided for in this Section 4.8 are cumulative and will become effective immediately after the record date or, if no record date is fixed, the effective date of the event which results in such adjustments.







 



	
4.9

	
Determination of Adjustments







 


If any questions will at any time arise with respect to the Exercise Price or any adjustment provided for in Section 4.8, such questions will be conclusively determined by the Company’s Auditors, or, if they decline to so act any other firm of certified public accountants in the United States of America that the Company may designate and who will have access to all appropriate records and such determination will be binding upon the Company and the Holders of the Warrants.


 



5.  COVENANTS BY THE COMPANY




 



	
5.1

	
Reservation of Shares







 


The Company will reserve and there will remain unissued out of its authorized capital a sufficient number of shares to satisfy the rights of purchase provided for herein and in the Warrants should the Holders of all the Warrants from time to time outstanding determine to exercise such rights in respect of all shares which they are or may be entitled to purchase pursuant thereto and hereto.


 



6.  WAIVER OF CERTAIN RIGHTS




 




	
6.1

	
Immunity of Shareholders, etc.









 


The Warrant Holder, as part of the consideration for the issue of the Warrants, waives and will not have any right, cause of action or remedy now or hereafter existing in any jurisdiction against any past, present or future incorporator, shareholder, Director or Officer (as such) of the Company for the issue of shares pursuant to any Warrant or on any covenant, agreement, representation or warranty by the Company herein contained or in the Warrant.


 



7.  MODIFICATION OF TERMS, MERGER, SUCCESSORS




 


7.1 Modification of Terms and Conditions for Certain Purposes


 


From time to time the Company may, subject to the provisions of these presents, modify the Terms and Conditions hereof, for the purpose of correction or rectification of any ambiguities, defective provisions, errors or omissions herein.


 


7.2 Warrants Not Transferable


 


The Warrant and all rights attached to it are not transferable.


 




  





18











  






 


FORM OF SUBSCRIPTION


 



	
TO:

	
Intelimax Media Inc.







 



	
  

	
555 W. Hastings, Suite 2320,Vancouver, British Columbia, V6B 4N4












 


The undersigned Holder of the within Warrants hereby subscribes for ____________ common shares (the “Shares”) of Intelimax Media Inc. (the “Company) pursuant to the within Warrants at US$0.30 per Share on the terms specified in the said Warrants.  This subscription is accompanied by a certified cheque or bank draft payable to or to the order of the Company for the whole amount of the purchase price of the Shares.


 


The undersigned hereby directs that the Shares be registered as follows:








	
NAME(S) IN FULL

	  	
ADDRESS(ES)

	  	
NUMBER OF SHARES


	  	  	  	  	  
	  	  	  	  	  
	  	  	
TOTAL:

	  	  





 


(Please print full name in which share certificates are to be issued, stating whether Mr., Mrs. or Miss is applicable).


 


DATED this ________  day of __________________ , ______.


 


In the presence of:


 







 



	
________________________________________ 


Signature of Witness

	
____________________________________________ 


Signature of Warrant Holder







 



  




Please print below your name and address in full.


 


Name (Mr./Mrs./Miss) _______________________________________                                                                                                                     


 


Address ________________________________________                                


 


 


INSTRUCTIONS FOR SUBSCRIPTION


 


The signature to the subscription must correspond in every particular with the name written upon the face of the Warrant without alteration or enlargement or any change whatever.  If there is more than one subscriber, all must sign.


 


In the case of persons signing by agent or attorney or by personal representative(s), the authority of such agent, attorney or representative(s) to sign must be proven to the satisfaction of the Company.


 


If the Warrant certificate and the form of subscription are being forwarded by mail, registered mail must be employed.


 


19