Exhibit 4.1

 




12% CONVERTIBLE BOND PURCHASE AGREEMENT


 


This 12% Convertible Bond Purchase Agreement
(this “Agreement”), is made and entered as of _________________, 2014 by and between Staffing 360 Solutions,
Inc., a publicly held Nevada company (OTCBB: STAF) (“STAF” or the “Company”), and the investor
listed on the signature page hereto (“Buyer”), with reference to the following facts:


 


A.The Company is
a fully reporting Over the Counter Bulletin Board public company whose common stock, par value $.00001 per share (the “Common
Stock”) is registered under Section 12 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”);


 


B.The Company is
offering for sale 12% convertible bonds (each a “Bond”, collectively, the “Bonds”) in the
aggregate principal amount of up to $4,000,000, with the understanding the principal amount may be increased up to $6,000,000 at
the Company’s sole discretion (the “Offering”);


 


C.The Company and
the Buyer each understand that the Bonds may be sold subject to the Selected Dealer Agreement (the “Placement Agent Agreement”),
among the Company and Accelerated Capital Group, a FINRA registered broker/dealer (the “Placement Agent”);


 


E.On the terms
and subject to the conditions of this Agreement, Buyer is willing to purchase a Bond.


 


NOW THEREFORE, with
reference to the foregoing facts, the Company and Buyer agree as follows:


 


1.Agreement to Purchase and Sell
Bond.


 


1.1The
Company hereby agrees to sell to Buyer, and Buyer hereby agrees to purchase from the Company, a Bond in the principal amount set
forth on the signature page hereto (the “Principal Amount”). The purchase price for the Bond is the principal amount
of the Bond, provided however, the minimum amount of an investment in the Bonds by each Buyer shall be in the principal amount
of $50,000, although the Company, in its sole discretion, may accept subscriptions for less. The Bond shall be in the form of Exhibit D
to the Subscription Booklet, completed with the date of issuance and principal amount.


 


1.2Within
two business days from the execution of this Agreement, Buyer shall wire transfer an amount equal to the respective purchase price
for the Bonds to the Escrow Agent. If the Buyer fails to make such wire transfer within such two-day period, in addition to any
other rights and remedies the Company may have, it may terminate this Agreement. The wiring instructions are attached hereto.


 






    	 



    	 



    

 


1.3The
subscription amounts paid by a Buyer solicited through the Placement Agent will be deposited in the escrow account. A closing shall
take place on such date and time specified by the Company and Placement Agent. Any funds raised directly by the Company will be
placed into the Company’s operating account and will be deemed accepted and immediately available to the Company. At the
closing, the Company shall issue the Bond to Buyer. The offering period will terminate upon the earlier to occur of (i) the date
the Offering Amount is sold or (ii) April 30, 2014; provided, however, that such offering period may be extended
without notice to the Buyers for up to three (3) additional 30 day periods.


 


1.4Payment
of the Bonds will be made on October 15, 2014 (the “Maturity Date”), unless earlier converted. Each Buyer must notify
the Company by October 15, 2014 whether payment will be made in the form of cash or as PIK (in comparably valued Common Stock of
the Company). If the Buyer chooses to be paid in cash, the Company will have 30 days from the Maturity Date to make the payment.
If no election is made by the Buyer, payment will be made in common stock.


 


1.5The
Buyer understands and agrees that Principal Amount and all accrued and unpaid interests are subject to a voluntary conversion at
the election of the Buyer. Prior to the Maturity Date, the Buyers in this Offering may elect to convert the Bond, in whole or in
part, including all accrued but unpaid coupon payments, into shares of Common Stock (the “Conversion Shares”) at the
price of $1.50 per share, unless an event of default occurs prior to such conversions. The Conversion Shares shall be restricted
pursuant to Rule 144 under the Securities Act.


 


1.6Equity
Consideration. The Buyer shall receive 5,000 shares (the “Equity Consideration Shares”, together with the Bonds
and the Conversion Shares, collectively the “Securities”) of the Company’s Common Stock for each $50,000 principal
amount of the Bond.


 


1.7Registration
Rights of Equity Consideration Shares and Conversion Shares.


 






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1.7.1Piggy-Back Rights.
If at any time the Company proposes to file a registration statement under the Securities Act with respect to an offering of equity
securities, or securities or other obligations exercisable or exchangeable for, or convertible into, equity securities, by the
Company for its own account or for security holders of the Company for their account (or by the Company and by security holders
of the Company), other than a registration statement (i) filed in connection with an offering of securities to employees or
directors of the Company pursuant to any employee stock option or other benefit plan, (ii) filed on Form S-4 or S-8 or any
successor to such forms, (iii) for an exchange offer or offering of securities solely to the Company’s existing security
holders, (iv)  for a dividend reinvestment plan, or (v) solely in connection with a merger, share capital exchange, asset
acquisition, share purchase, reorganization, amalgamation, subsequent liquidation, or other similar business transaction that results
in all of the Company’s shareholders having the right to exchange their common stock for cash, securities or other property
of a non-capital raising bona fide business transaction, then the Company shall (x) give written notice of such proposed filing
to the holders of the Equity Consideration Shares and the Conversion Shares as soon as practicable but in no event less than three
(3) business days before the anticipated filing date, which notice shall describe the amount and type of securities to be included
in such offering, the intended method(s) of distribution, and the name of the proposed managing underwriter or underwriters, if
any, of the offering, and (y) offer to the holder of the Equity Consideration Shares and the Conversion Shares in such notice
the opportunity to register the sale of such number of the Equity Consideration Shares and the Conversion Shares as such holders
may request in writing within three (3) business days following receipt by such holder of such notice (a “Piggy-Back Registration”),
provided, however, the holder of the Equity Consideration Shares and the Conversion Shares shall only be entitled to one Piggy-Back
Registration right. The Company shall include in such registration statement such Equity Consideration Shares and the Conversion
Shares that are requested to be included therein within three (3) business days after the receipt by such holder of any such notice,
on the same terms and conditions as any similar securities of the Company. If at any time after giving written notice of its intention
to register any securities and prior to the effective date of the registration statement filed in connection with such registration,
the Company shall determine for any reason not to register or to delay registration of such securities, the Company may, at its
election, give written notice of such determination to each holder of the Equity Consideration Shares and the Conversion Shares,
and (x) in the case of a determination not to register, shall be relieved of its obligation to register any Equity Consideration
Shares or Conversion Shares in connection with such registration, and (y) in the case of a determination to delay registering,
shall be permitted to delay registering any Equity Consideration Shares or Conversion Shares for the same period as the delay in
registering such other securities. If the offering pursuant to a Piggy-Back Registration is to be an underwritten offering, then
the holder making a request for its Equity Consideration Shares or Conversion Shares to be included therein must permit the sale
or other disposition of such Equity Consideration Shares or Conversion Shares in accordance with the intended method(s) of distribution
thereof. The holder of the Equity Consideration Shares and the Conversion Shares proposing to distribute their securities through
a Piggy-Back Registration that involves an underwriter or underwriters shall enter into an underwriting agreement in customary
form with the underwriter or underwriters selected for such Piggy-Back Registration and the holder of the Equity Consideration
Shares and the Conversion Shares shall be responsible for any fees or commissions due to such underwriters in connection with the
sale of such Equity Consideration Shares and Conversion Shares.


 


(i)Reduction
of Offering. If the managing underwriter or underwriters for a Piggy-Back Registration that is to be an underwritten offering
advises the Company and the holder of Equity Consideration Shares and Conversion Shares in writing that the dollar amount or number
of the Common Stock which the Company desires to sell, as to which registration has been demanded pursuant to written contractual
arrangements with persons other than the holders of the Equity Consideration Shares and Conversion Shares as to which registration
has been requested under this section and the securities as to which registration has been requested pursuant to the written contractual
piggy-back registration rights of other security holders of the Company exceeds the maximum dollar amount or maximum number of
securities that can be sold in such offering without adversely affecting the proposed offering price, the timing, the distribution
method, or the probability of success of such offering (such maximum dollar amount or maximum number of securities, as applicable,
the “Maximum Number of Securities”), then the Company shall include in any such registration:


 






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(1)If the
registration is undertaken for the Company’s account: (A) first, the shares of Common Stock that the Company desires to sell;
and (B) to the extent of the Maximum Number of Securities, the shares of Common Stock, pro-rata among holders, for the account
of any persons, including Buyers in this Offering for which the Company is obligated to register pursuant to contractual piggy-back
registration rights such as in this Agreement.


 


(ii)Withdrawal.
Any holder of Equity Consideration Shares and Conversion Shares may elect to withdraw such holder’s request for inclusion
of the Equity Consideration Shares and Conversion Shares in any Piggy-Back Registration by giving written notice to the Company
of such request to withdraw prior to the effectiveness of the registration statement. The Company (whether on its own determination
or as the result of a withdrawal by persons making a demand pursuant to written contractual obligations) may withdraw a registration
statement at any time prior to the effectiveness of the registration statement. Notwithstanding any such withdrawal, the Company
shall pay all expenses incurred by the holders of the Equity Consideration Shares and Conversion Shares in connection with such
Piggy-Back Registration.


 


(iii)Limitations
on Piggy-Back Registration Rights.  The Piggy-Back Registration Rights granted pursuant to this Section shall expire
upon the date such Equity Consideration Shares and Conversion Shares are eligible for sale without registration pursuant to Rule
144.  Further, the Company has the right to exclude the holder of the Equity Consideration Shares and Conversion Shares from
any registration statement in the event the Company is contractually obligated to exclude such securities. Furthermore, in the
event that the registration statement covers shares of the Company, the Company, or the underwriter shall have a right to require
the Holders to a six (6) month lock-up period from the date of effectiveness of the registration statement.


 


(iv)Obligations
of the Buyer.  In connection with any registration statement utilized by the Company to satisfy the registration rights
pursuant to this section, the Buyer agrees to cooperate with the Company in connection with the preparation of the registration
statement, and Buyer agrees that it will (i) respond within three (3) Business Days to any written request by the Company
to provide or verify information regarding Buyer or his Equity Consideration Shares and the Conversion Shares (including the proposed
manner of sale) that may be required to be included in such registration statement and related prospectus pursuant to the rules and
regulations of the Securities and Exchange Commission, and (ii) provide in a timely manner information regarding the proposed
distribution by the Buyer of the Equity Consideration Shares and the Conversion Shares and such other information as may be requested
by the Company from time to time in connection with the preparation of and for inclusion in the registration statement and related
prospectus.


 






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2.Definitions


 


For purposes of this
Agreement, the following terms shall have the meanings set forth below:


 


“Securities
Act” shall mean the Securities Act of 1933, as amended.


 


“Transfer”
shall mean sell, assign, transfer, pledge, grant a security interest in, or otherwise dispose of, with or without consideration.


 


3.Representations and Warranties
of the Company


 


 


The Company represents
and warrants to the Buyer that:


 


3.1The
Company is a Securities and Exchange Commission (“SEC”) fully reporting public company approved for trading
on the Over–the-Counter Bulletin Board, validly existing and in good standing under the laws of Nevada and has all requisite
power and authority to own, lease and operate its properties and assets and to carry on its business as now being conducted and
as proposed to be conducted.


 


3.2This
Agreement and the Securities offered hereby have been duly authorized by the Board of Directors of the Company. This Agreement
has been duly executed and delivered by the Company and constitutes a valid and legally binding obligation of the Company enforceable
against the Company in accordance with its terms, subject to the effect of bankruptcy, insolvency, reorganization, moratorium,
fraudulent conveyance and other similar laws relating to or affecting creditors' rights generally, or the availability of equitable
remedies.


 


3.3Upon
execution and delivery at the respective Closings, the Bonds will be duly executed and delivered by the Company and will constitute
a valid and legally binding obligation of the Company enforceable against the Company in accordance with its terms, subject to
the effect of bankruptcy, insolvency, reorganization, moratorium, fraudulent conveyance and other similar laws relating to or affecting
creditors' rights generally, or the availability of equitable remedies. Upon issuance, the Equity Consideration Shares and the
Conversion Shares will be duly and validly issued, fully paid and non-assessable.


 


3.4The
execution and delivery of this Agreement and the Bonds do not and will not conflict with, result in a breach of any provision of,
or constitute a default (or an event which would constitute a default upon the giving of any required notice or upon a lapse of
time) under the Company’s organizational documents or the provisions of any agreement, contract or administrative order,
consent decree or other instrument to which the Company is a party.


 


3.5There
is no pending or, to the knowledge of the Company, threatened litigation to which the Company is a party and the Company is not
subject to any judgment, order, writ, injunction, decree or regulatory directive or agreement.


 






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4.Representations, Warranties and
Agreements of Buyer


 


Buyer represents and
warrants to, and agrees with, the Company as follows:


 


4.1Buyer
will acquire the Bond and the Equity Consideration Shares, and if the Bond is converted, the Conversion Shares for Buyer’s
own account, for investment purposes only.


 


4.2Buyer
understands that an investment in the Bonds, the Equity Consideration Shares and the Conversion Shares involve a high degree
of risk, and Buyer represents that it has the financial ability to bear the economic risk of such investment, including a complete
loss of such investment.


 


4.3Buyer
understands that the Company is cash flow negative and will have no source of payment of the Bonds other than the proceeds raised
in the Mezzanine Financing or conversion of the Bonds into the Conversion Shares.


 


4.4Buyer
is an “accredited investor” as that term is defined in Rule 501(a) under Regulation D promulgated pursuant
to the Securities Act, and the statements and representations in the accredited investor certification attached as Exhibit E
to the Subscription Booklet are true and correct;


 


4.5Buyer
understands that neither the Bonds nor the Equity Consideration Shares, nor the Conversion Shares have been or will be registered
under the Securities Act or under any state securities laws, other than piggy-back registration rights, and they will be “restricted
securities” within the meaning of Rule 144 under the Securities Act.


 


4.6Buyer
believes that he or she has received all the information Buyer considers necessary or appropriate for deciding whether to purchase
the Bonds, including information regarding the Company, and Buyer has had an opportunity to ask questions and receive answers from
the Company and its officers and directors regarding the business, prospects and financial condition of the Company. The Buyer
and the Buyer’s attorney, accountant, purchaser representative and/or tax advisor (collectively, “Advisors”),
have received and have carefully reviewed the this Agreement and the Bond (collectively, the “Transaction Documents”)
and all other documents requested by the Buyer or its Advisors, and understand the information contained therein, prior to the
execution of this Agreement;


 


4.7Buyer
has had the opportunity to review the Company’s filings with the SEC, including but not limited to the Form 10-K for the
year ended May 31, 2013 filed with the SEC on September 13, 2013 and the Form 10-Q for the quarter ended August 31, 2013 filed
with the SEC on October 18, 2013, and the Form 10-Q for the quarter ended November 30, 2013 filed with the SEC on January 14,
2014 (the “SEC Reports”) and Buyer has received and reviewed the Subscription Booklet, and all the information,
both written and oral, that it desires. Without limiting the generality of the foregoing, Buyer has been furnished with or has
had the opportunity to acquire, and to review, all information (including copies of all of the Company’s publicly available
documents on the EDGAR system maintained by the SEC at http://www.sec.gov/edgar/searchedgar/webusers.htm
and the SEC Reports), both written and oral, that it desires with respect to the Company’s business, management,
financial affairs and prospects. In determining whether to make this investment, Buyer has relied solely on Buyer’s own
knowledge and understanding of the Company and its business based upon Buyer’s own due diligence investigations and the
information furnished pursuant to this paragraph. Buyer understands that no person has been authorized to give any information
or to make any representations which were not furnished pursuant to this paragraph and Buyer has not relied on any other representations
or information.


 






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4.8The
Buyer understands that neither the SEC nor any state securities commission has approved or disapproved of the Securities or passed
upon or endorsed the merits of the Offering and has not been reviewed by any Federal, state or other regulatory authority;


 


4.9The
Buyer has not been furnished with any oral representation or oral information in connection with the offering of the Securities
that is not contained in, or is in any way contrary to or inconsistent with, statements made in this Agreement;


 


4.10The
Buyer has taken no action which would give rise to any claim by any person for brokerage commissions, finders’ fees or the
like relating to this Agreement or the transactions contemplated hereby;


 


4.11The
Buyer, either alone or together with its Advisors has such knowledge and experience in financial, tax, and business matters, and,
in particular, investments in securities, so as to enable it to utilize the information made available to it in connection with
the Offering to evaluate the merits and risks of an investment in the Securities and the Company and to make an informed investment
decision with respect thereto;


 


4.12The
Buyer is not relying on the Company, or any of its respective employees or agents with respect to the legal, tax, economic and
related considerations of an investment in any of the Securities and the Buyer has relied on the advice of, or has consulted with,
only its own Advisors;


 


4.13Buyer
understands that the Company intends to conduct future rounds of financing in addition to this Offering, including but not limited
to an anticipated Mezzanine Financing. Buyer understands that the Company could use the proceeds from such Mezzanine Financing
for repayment to the Buyers of the respective amounts purchased for the Bonds subscribed for in this Offering. Buyer understands
that no commitments have been made for such Mezzanine Financing and such Mezzanine Financing may not be consummated at all. In
the event the Mezzanine Financing is not consummated, the Company will likely default on the Bonds issued in this Offering;


 


4.14Buyer
understands that the Placement Agent is entitled to a 10% commission of the gross proceeds from the sale of the Bonds raised by
the Placement Agent in this Offering and is entitled to shares of Common Stock equal to an amount up to 10% of the aggregate number
of shares of Common Stock issued in connection with funds raised by the Placement Agent in this Offering;


 


4.15No
representations or warranties have been made to Buyer by the Company, or any officer, employee, agent, affiliate or subsidiary
of the Company, other than the representations of the Company contained herein, and in subscribing for the Securities, Buyer is
not relying upon any representations other than those contained in this Agreement. Buyer further acknowledges that the Company
is a publicly reporting company and that additional information about the Company can be retrieved from the SEC’s website.


 






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4.16Buyer
understands that there is no minimum amount which must be raised before the Company holds an initial closing of this Offering and
that the Company will not have enough money to implement its business plan unless it raises a substantial percentage of the Offering
amount (and then in the Mezzanine Financing and subsequent financings). Buyer acknowledges that if the Company does not raise a
substantial percentage of the Offering amount, it will lead to the complete loss of Buyer’s investment.


 


5. Transfer Restrictions; Legends.


 


5.1The
Buyer understands that (i) the Securities have not been registered under the Securities Act; (ii) the Securities
are being offered and sold pursuant to an exemption from registration, based in part upon the Company’s reliance upon the
statements and representations made by the Buyer in this Agreement, and that the Securities must be held by the Buyer indefinitely,
and that the Buyer must, therefore, bear the economic risk of such investment indefinitely, unless a subsequent disposition thereof
is registered under the Securities Act or is exempt from such registration; (iii) each Certificate representing the Securities
will be endorsed with a legend substantially in the following form until the earlier of (1) such date as the Securities have been
registered for resale by the Buyer or (2) the date the Securities are eligible for sale under Rule 144 under the Securities Act
or any successor rule (“Rule 144”):


 


 


“THE SECURITIES REPRESENTED BY
THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933 (THE “ACT”) AND ARE “RESTRICTED SECURITIES”
AS THAT TERM IS DEFINED IN RULE 144 UNDER THE ACT. THE SECURITIES MAY NOT BE OFFERED FOR SALE, SOLD OR OTHERWISE TRANSFERRED EXCEPT
PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE ACT OR PURSUANT TO AN EXEMPTION FROM REGISTRATION UNDER THE ACT, THE
AVAILABILITY OF WHICH IS TO BE ESTABLISHED TO THE REASONABLE SATISFACTION OF THE ISSUER.”


 


 


5.2Any
legend required by the Blue Sky laws of any state to the extent such laws are applicable to the shares represented by the certificate
so legended.


 


5.3Each
Buyer, severally and not jointly with the other Buyers, agrees that the removal of the restrictive legend from certificates representing
Securities as set forth in this Section is predicated upon the Company’s reliance that the Buyer will sell any Securities
pursuant to either the registration requirements of the Securities Act, including any applicable prospectus delivery requirements,
or an exemption therefrom.


 


5.4The
Buyer acknowledges that the Securities have not been recommended by any Federal or state securities commission or regulatory authority.
In making an investment decision, investors must rely on their own examination of Company and the terms of the Offering, including
the merits and risks involved. Furthermore, the foregoing authorities have not confirmed the accuracy or determined the adequacy
of this Agreement. Any representation to the contrary is a criminal offense. The Securities are subject to restrictions on transferability
and resale and may not be transferred or resold except as permitted under the Securities Act, and the applicable state securities
laws, pursuant to registration or exemption therefrom. Buyers should be aware that they will be required to bear the financial
risks of this investment for an indefinite period of time;


 






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6.Miscellaneous


 


6.1Notices.
All notices, requests, demands and other communications (collectively, “Notices”) given pursuant to this Agreement
shall be in writing, and shall be delivered by personal service, courier, facsimile transmission or by United States first class,
registered or certified mail, postage prepaid, addressed to the party at the address set forth on the signature page to this Agreement.
Any Notice, other than a Notice sent by registered or certified mail, shall be effective when received; a Notice sent by registered
or certified mail, postage prepaid return receipt requested, shall be effective on the earlier of when received or the fifth day
following deposit in the United States mails. Any party may from time to time change its address for further Notices hereunder
by giving notice to the other party in the manner prescribed in this Section.


 


6.2Entire
Agreement. This Agreement and related Exhibits contain the sole and entire agreement and understanding of the parties
with respect to the entire subject matter of this Agreement, and any and all prior discussions, negotiations, commitments and understandings,
whether oral or otherwise, related to the subject matter of this Agreement are hereby merged herein.


 


6.3Successors.
This Agreement shall be binding upon and inure to the benefit of the parties to this Agreement and their respective successors,
heirs and personal representatives.


 


6.4Waiver
and Amendment. No provision of this Agreement may be waived unless in writing signed by all the parties to this Agreement,
and waiver of any one provision of this Agreement shall not be deemed to be a waiver of any other provision. This Agreement may
be amended only by a written agreement executed by all of the parties to this Agreement.


 


6.5Governing
Law. This Agreement shall be construed in accordance with the laws of the State of New York without giving effect to
the principles of conflicts of law thereof.


 


6.6Captions.
The various captions of this Agreement are for reference only and shall not be considered or referred to in resolving questions
of interpretation of this Agreement.


 


6.7Execution.
This Agreement may be executed in two or more counterparts, all of which when taken together shall be considered one and the same
agreement and shall become effective when counterparts have been signed by each party and delivered to the other party, it being
understood that both parties need not sign the same counterpart. In the event that any signature is delivered by facsimile transmission
or by email delivery of a “PDF” format data file, such signature shall create a valid and binding obligation of the
party executing (or on whose behalf such signature is executed) with the same force and effect as if such facsimile or “pdf”
signature page were an original thereof.


 






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6.8Blue
Sky Qualification. The purchase of Securities pursuant to this Agreement is expressly conditioned upon the exemption
from qualification of the offer and sale of the Securities from applicable Federal and state securities laws.


 


6.9Confidentiality.
The Buyer acknowledges and agrees that any information or data the Buyer has acquired from or about the Company not otherwise
properly in the public domain, was received in confidence. The Buyer agrees not to divulge, communicate or disclose, except as
may be required by law or for the performance of this Agreement, or use to the detriment of the Company or for the benefit of any
other person or persons, or misuse in any way, any confidential information of the Company, including any trade or business secrets
of the Company and any business materials that are treated by the Company as confidential or proprietary, including, without limitation,
confidential information obtained by or given to the Company about or belonging to third parties.


 






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IN WITNESS WHEREOF,
the parties have executed this Agreement as of the day and year first written above.


 


 


	$	 	 
	Bond Amount	 


 


Manner in which Title is to be held
(Please Check One):


 


	1.	___	Individual	7.	___	Trust/Estate/Pension or Profit Sharing Plan

Date Opened:______________
	2.	___	Joint Tenants with Right of Survivorship	8.	___	As a Custodian for

________________________________

Under the Uniform Gift to Minors Act of the State of

________________________________
	3.	___	Community Property	9.	___	Married with Separate Property
	4.	___	Tenants in Common	10.	___	Keogh
	5.	___	Corporation/Partnership/ Limited Liability Company	11.	___	Tenants by the Entirety
	6.	___	IRA	12.	___	Foundation described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended.


 





	IF MORE THAN ONE SUBSCRIBER, EACH SUBSCRIBER MUST SIGN:
	·	INDIVIDUAL SUBSCRIBERS MUST COMPLETE PAGE 11
	·	SUBSCRIBERS WHICH ARE ENTITIES MUST COMPLETE PAGE 12




 






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EXECUTION BY NATURAL PERSONS


 


 


 


	 
	Exact Name in Which Title is to be Held


 


	 	 	 
	Name (Please Print)	 	Name of Additional Subscriber
	 	 	 
	 	 	 
	Residence: Number and Street	 	Address of Additional Subscriber
	 	 	 
	 	 	 
	City, State and Zip Code	 	City, State and Zip Code
	 	 	 
	 	 	 
	Social Security Number	 	Social Security Number
	 	 	 
	 	 	 
	Telephone Number	 	Telephone Number
	 	 	 
	 	 	 
	Fax Number (if available)	 	Fax Number (if available)
	 	 	 
	 	 	 
	E-Mail (if available)	 	E-Mail (if available)
	 	 	 
	 	 	 
	(Signature)	 	(Signature of Additional Subscriber)
	 	 	 


 


	
        *If Subscriber is a Registered Representative
        with a FINRA member firm, have the following acknowledgement signed by the appropriate party:

         
	 
	The undersigned FINRA member firm acknowledges receipt of the
notice required by Rule 3050 of the FINRA Conduct Rules	 


 


 


	 	 	ACCEPTED this ____ day of __________ 2014, on behalf of Staffing 360 Solutions, Inc.
	Name of FINRA Firm	 	 
	 	 	 
	By: 	 	 	By:	 
	 	Name:	 	 	Name:
	 	Title:	 	 	Title:


 






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EXECUTION BY SUBSCRIBER WHICH IS AN
ENTITY


 


(Corporation, Partnership, Trust, Etc.)


 


	 
	Name of Entity (Please Print)
	Date of Incorporation or Organization:
	 
	State of Principal Office:


 


	Federal Taxpayer Identification Number:	 


 


 


	 
	Office Address
	 
	City, State and Zip Code
	 
	Telephone Number
	 
	Fax Number (if available)
	 
	E-Mail (if available)


 


	[seal]	 	 	By:	 
	 	 	 	 	Name:
	Attest:	 	 	 	Title:
	(If Entity is a Corporation)	 	 	 


 


	*If Subscriber is a Registered Representative with a FINRA member firm, have the following acknowledgement signed by the appropriate party:	 
	 	 
	The undersigned FINRA member firm acknowledges receipt of the notice

required by Rule 3050 of the FINRA

Conduct Rules	 


 


	 


 


	 	 	 	ACCEPTED this ____ day of __________ 2014, on behalf of Staffing 360 Solutions, Inc.
	Name of FINRA Firm	 	 	 
	 	 	 	 	 
	By:	 	 	By:	 
	 	Name:	 	 	Name:
	 	 Title:	 	 	Title:


 






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