Document:

Anavex Life Sciences Corp.: Exhibit 10.4  - Filed by newsfilecorp.com

EXHIBIT A

FORM OF WARRANT

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 “1933 ACT”), AND, ACCORDINGLY, MAY NOT
BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER
THE 1933 ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT
SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE 1993 ACT AND IN ACCORDANCE WITH
APPLICABLE STATE SECURITIES LAWS.

THESE WARRANTS WILL EXPIRE AND BECOME NULL AND VOID 
AT 12:01
A.M. ON _________.

SHARE PURCHASE WARRANTS TO PURCHASE SHARE OF COMMON STOCK OF

ANAVEX LIFE SCIENCES CORP.

     THIS IS TO CERTIFY THAT
________(the "Holder") of _______common shares of Anavex Life Sciences Corp. has
the right to purchase, upon and subject to the terms and conditions hereinafter
referred to, up to _______fully paid and non-assessable shares of common stock
(the "Shares") in the capital of Anavex Life Sciences Corp. (hereinafter called
the "Company") on or before 11:59p.m. on _______(the "Expiry Date") at a
price per Share of US$_______(the "Exercise Price") on the terms and conditions
attached hereto as Appendix A (the "Terms and Conditions").

	 	1. 	
      ONE (1) WARRANT AND THE EXERCISE PRICE ARE REQUIRED TO
      PURCHASE ONE SHARE. THIS CERTIFICATE REPRESENTS
      _________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 _______.

ANAVEX LIFE SCIENCES CORP.

Per:
___________________
       Authorized
Signatory

APPENDIX A

TERMS AND CONDITIONS dated _________, attached to the Warrants
issued by Anavex Life Sciences Corp.

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 Anavex Life Sciences Corp. 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 shares of common stock 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 Warrant and the terms hereof are governed by the laws of
the State of Nevada and the federal laws applicable therein. The Holder, in the
Holder’s personal or corporate capacity and, if applicable, on behalf of each
beneficial purchaser for whom the Holder is acting, irrevocably attorns to the
jurisdiction of the courts of the State of Nevada.

- 2 -

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 Warrants 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
as 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 Holder

Any notice required or permitted to be given to the Holder 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 labor 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 set forth below or such
other address as the Company may specify by notice in writing to the Holder, 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:

- 3 -

Anavex Life Sciences Corp.
27
Marathonos Ave., Pallini, 17455 Athens, Greece

Attention: President

Fax No. +1 250 764 9701

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 check payable to the Company 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, her or them at
      his, her 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 the Holder 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 the Holder is entitled
to purchase pursuant to the surrendered Warrant and which are 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 -

4.7 Subscription Price

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

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. WAIVER OF CERTAIN RIGHTS

5.1 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.

- 5 -

6. MODIFICATION OF TERMS, ETC.

6.1 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.

6.2 Warrants Not Transferable

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

DATED as of the date first above written in these Terms and
Conditions.

	 	ANAVEX LIFE SCIENCES CORP.
  
	 	  
	 	  
	 	Per: 	 
	 		Authorized
    Signatory  

- 6 -

FORM OF SUBSCRIPTION

	TO: 	Anavex Life Sciences Corp. 
		27 Marathonos Ave.  
	  	Pallini, 17455 
	  	Athens, Greece 

The undersigned Holder of the within Warrants hereby subscribes
for ____________shares of common stock (the "Shares") of Anavex Life Sciences
Corp. (the "Company") pursuant to the within Warrants at US$2.25 per Share on
the terms specified in the said Warrants. This subscription is accompanied by a
certified check 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 represents that, at the time of the exercise of
these Warrants, all of the representations and warranties contained in Section 6
of the Subscription Agreement between the Company and the undersigned pursuant
to which these Warrants were issued are true and accurate.

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.Wolverine Exploration Inc.: Exhibit 10.1 - Filed by newsfilecorp.com

(U.S. ACCREDITED PURCHASERS ONLY)

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.

WOLVERINE EXPLORATION INC.

PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT 

UNITED STATES ACCREDITED INVESTORS

INSTRUCTIONS TO PURCHASER

	1. 	
      This Subscription form is for use by United States
      Accredited Investors.

	 	 
	2. 	
      COMPLETE the information on page 2 of this
      Subscription Agreement.

	 	 
	3. 	
      COMPLETE the Questionnaire attached on page 5 to
      this Subscription Agreement (the "Questionnaire").

	 	 
	4. 	
      All other information must be filled in where
      appropriate.

This is Page 2 of 11 pages of a subscription agreement and
related appendices, schedules and forms. Collectively, these pages together are
referred to as the “Subscription Agreement”.

PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT

TO: WOLVERINE EXPLORATION Inc. (the “Issuer”), of 4055
Maclean Road, Quesnel, BC V2J 6V5.

Subject and pursuant to the terms set out in the Terms on pages
3 to 4 of this Subscription Agreement, the General Provisions on pages 7 to 12
of this Subscription Agreement and the other schedules and appendices attached
which are hereby incorporated by reference, the Purchaser hereby irrevocably
subscribes for, and on Closing will purchase from the Issuer, the following
securities at the following price:

	_____________________ Shares 
	US$0.03 per Unit for a total purchase price of US$
      ___________________ 
	The Purchaser owns, directly or indirectly, the following
      securities of the Issuer: 
	 
    
	[Check if applicable] The Purchaser is [x] an affiliate
      of the Issuer or [ ] a member of the professional group

The Purchaser directs the Issuer to issue, register and deliver
the certificates representing the Shares 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 Purchaser this _____day of
____________________, 2010. By executing this Subscription Agreement, the
Purchaser certifies that the Purchaser and any beneficial purchaser for whom the
Purchaser is acting is resident in the jurisdiction shown as the “Address of
Purchaser”. 

	WITNESS: 	 	EXECUTION BY PURCHASER: 
	  	 	X 
	Signature of Witness
    	 	Signature of individual (if Purchaser is an individual)
    
	  	 	X 
	Name of Witness 	 	Authorized signatory (if Purchaser is not an
      individual) 
	 
    	 	  
	Address of Witness
    	 	Name of
      Purchaser (please print) 
	 
    	 	  
	  	 	Name of
      authorized signatory (please print) 
	Accepted this
      __________________, 2010 	 	  
	WOLVERINE
      EXPLORATION INC. 	 	Address
      of Purchaser (residence) 
	Per: 	 	  
	  	 	*Telephone Number 
	Authorized Signatory
    	 	  
	  	 	*E-mail
      address 
	  	 	  
	  	 	*Social Security/Insurance No./Gov ID No.:
  

*Required from all Purchasers
By signing this acceptance,
the Issuer agrees to be bound by the Terms on pages 3 to 4 of this Subscription
Agreement, the General Provisions on pages 6 to 11 of this Subscription
Agreement and the other schedules and appendices incorporated by reference.
If funds are delivered to the Company’s lawyers, they are authorized to
release the funds to the Issuer without further authorization from the
Purchaser.

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 3 of 11 

TERMS

	Reference date of this Subscription
      Agreement 	
      ____________________, 2010 (the “Agreement Date”)
      

	 	
      

	The Offering 
	  	
      

	The Issuer 	
      WOLVERINE EXPLORATION INC. (the “Company or
      Issuer”) 

	  	
      

	Offering 	
      The offering consists of shares of common stock
      (“Shares”). 

	  	
      

	Purchased Securities 	
      The “Securities or Purchased Securities” under
      this Subscription Agreement are the Shares. 

	  	
      

	Total Amount 	
      This offering is not subject to any minimum or maximum
      offering. 

	  	
      

	Issue Price 	
      US$0.03 per Share. 

	  	
      

	Selling Jurisdictions 	
      The Shares may be sold in jurisdictions where they may be
      lawfully sold (the “Selling Jurisdictions”). 

	  	
      

	Exemptions 	
      The offering will be made in accordance with the
      following exemptions: 

	 	
       

		
           (a) the Accredited Investor
      exemption as defined by Regulation D promulgated under the 1933 Act
  

	  	
      

		
           (b) such other exemptions as may
      be available the securities laws of the Selling Jurisdictions. 

	  	
      

	No Registration of Securities 	
      The Securities will be registered with the SEC on a
      commercially reasonable efforts basis and will also be tradable in
      compliance with Rule 144 restricted periods. 

	  	
      

	Resale restrictions and legends 	
      The Purchaser acknowledges that the certificates
      representing the Purchased Securities will bear the following legends:
    

	  	
      

		
      “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.” 

	  	
      

		
      Purchasers are advised to consult with their own legal
      counsel or advisors to determine the resale restrictions that may be
      applicable to them. 

	  	
      

	Closing Date 	
      The completion of the sale and purchase of the Shares
      will take place in one or more closings, on a date or dates as agreed to
      by the Issuer and the Purchaser (the “Closing Date”). 

	  	
      

	 The Issuer 
	  	
      

	Jurisdiction of organization 	
      The Issuer is incorporated under the laws of the State of
      Nevada. 

	  	
      

	“Securities Legislation Applicable to the
      Issuer” 	
      The “Securities Legislation Applicable to the
      Issuer” is the U.S. Securities Exchange Act of 1934, and the
      Securities Commission having jurisdiction over the Issuer is the United
      States Securities and Exchange Commission. 

End of Terms

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 4 of 11 

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 Purchaser 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
Purchaser 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
Purchaser 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 Purchaser 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 Purchaser 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, 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 $300,000 in each of those years and
      has a reasonable expectation of reaching the same income level in the
      current year. 

	  	 	
      

	__________ 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 301(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). 

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 5 of 11 

	__________ 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 Purchaser 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
      Purchaser’s status as an Accredited Investor. 

	
       
	
      

	
      If the Purchaser 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 Purchaser hereby certifies that the information
      contained in this Questionnaire is complete and accurate and the Purchaser
      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
      Purchaser 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 _______________, 2010. 

	If a Corporation, Partnership or Other Entity: 	 	If an Individual: 
	  	 	  
	 	 	 
	Print of Type Name of Entity 	 	Signature 
	 	 	 
	 	 	 
	Signature of Authorized Signatory 	 	Print or Type Name 
	 	 	 
	 	 	 
	Type of Entity 	 	  

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 6 of 11 

GENERAL PROVISIONS

1.          
 DEFINITIONS

1.1          In
the Subscription Agreement (including the first (cover) page, the Terms on pages
3 to 4, these General Provisions and the other schedules, questionnaires and
appendices incorporated by reference), the following words have the following
meanings unless otherwise indicated:

	 	(a) 	
      “1933 Act” means the United States Securities Act
      of 1933, as amended;

	 	 	 
	 	(b) 	
      “Applicable Legislation” means the Securities
      Legislation Applicable to the Issuer (as defined on page 8) and all
      legislation incorporated in the definition of this term in other parts of
      the Subscription Agreement, together with the regulations and rules made
      and promulgated under that legislation and all administrative policy
      statements, blanket orders and rulings, notices and other administrative
      directions issued by the Commissions;

	 	 	 
	 	(c) 	
      “Closing” means the completion of the sale and
      purchase of the Purchased Securities;

	 	 	 
	 	(d) 	
      “Closing Date” has the meaning assigned in the
      Terms;

	 	 	 
	 	(e) 	
      “Closing Year” means the calendar year in which
      the Closing takes place;

	 	 	 
	 	(f) 	
      “Commissions” means the Commissions with
      Jurisdiction over the Issuer (as defined on page 4) and the securities
      commissions incorporated in the definition of this term in other parts of
      the Subscription Agreement;

	 	 	 
	 	(g) 	
      “Final Closing” means the last closing under the
      Private Placement;

	 	 	 
	 	(h) 	
      “General Provisions” means those portions of the
      Subscription Agreement headed “General Provisions” and contained on
      pages 7 to 12;

	 	 	 
	 	(i) 	
      “Private Placement” means the offering of the
      Purchased Securities on the terms and conditions of this Subscription
      Agreement;

	 	 	 
	 	(j) 	
      “Purchased Securities” has the meaning assigned in
      the Terms;

	 	 	 
	 	(k) 	
      “Regulatory Authorities” means the
    Commissions;

	 	 	 
	 	(l) 	
      “Securities” has the meaning assigned in the
      Terms;

	 	 	 
	 	(m) 	
      “Subscription Agreement” means the first (cover)
      page, the Terms on pages 3 to 4, the General Provisions and the other
      schedules and appendices incorporated by reference; and

	 	 	 
	 	(n) 	
      “Terms” means those portions of the Subscription
      Agreement headed “Terms” and contained on page 3.

1.2          In
the Subscription Agreement, the following terms have the meanings defined in
Regulation S under the 1933 Act: “Directed Selling Efforts”, “Foreign
Issuer”, “Substantial U.S. Market Interest”, “U.S. Person” and
“United States”.

1.3          In
the Subscription Agreement, unless otherwise specified, currencies are indicated
in U.S. dollars.

1.4          In
the Subscription Agreement, other words and phrases that are capitalized have
the meanings assigned to them in the body hereof.

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 7 of 11 

2.           
ACKNOWLEDGEMENTS, REPRESENTATIONS AND WARRANTIES OF PURCHASER

2.1         
Acknowledgements concerning offering

The Purchaser acknowledges that:

	 	(a) 	
      the Securities have not been registered under the 1933
      Act, or under any state securities or "blue sky" laws of any state of the
      United States, and are being offered only in a transaction not involving
      any public offering within the meaning of the 1933 Act, and, unless so
      registered, may not be offered or sold in the United States or to U.S.
      Persons (as defined herein), except 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 securities
      laws;

	 	 	 
	 	(b) 	
      the Company will refuse to register any transfer of the
      Securities not made in accordance with the provisions of Regulation S,
      pursuant to an effective registration statement under the 1933 Act or
      pursuant to an available exemption from, or in a transaction not subject
      to, the registration requirements of the 1933 Act;

	 	 	 
	 	(c) 	
      the Company has not undertaken, and will have no
      obligation, to register any of the Securities under the 1933
Act;

	 	 	 
	 	(d) 	
      the decision to execute this Subscription Agreement and
      purchase the Purchased Securities agreed to be purchased hereunder has not
      been based upon any oral or written representation as to fact or otherwise
      made by or on behalf of the Company and such decision is based entirely
      upon a review of information (the "Company Information") which has been
      provided by the Company to the Purchaser. If the Company has presented a
      business plan or any other type of corporate profile to the Purchaser, the
      Purchaser acknowledges that the business plan, the corporate profile and
      any projections or predictions contained in any such documents may not be
      achieved or be achievable;

	 	 	 
	 	(e) 	
      the Purchaser and the Purchaser'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 Purchaser;

	 	 	 
	 	(f) 	
      the books and records of the Company were available upon
      reasonable notice for inspection, subject to certain confidentiality
      restrictions, by the Purchaser 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
      Purchaser, the Purchaser's attorney and/or advisor(s);

	 	 	 
	 	(g) 	
      by execution hereof the Purchaser has waived the need for
      the Company to communicate its acceptance of the purchase of the Purchased
      Securities pursuant to this Subscription Agreement;

	 	 	 
	 	(h) 	
      the Company is entitled to rely on the representations
      and warranties and the statements and answers of the Purchaser contained
      in this Subscription Agreement and in the Questionnaire, and the Purchaser
      will hold harmless the Company from any loss or damage it may suffer as a
      result of the Purchaser's failure to correctly complete this Subscription
      Agreement or the Questionnaire;

	 	 	 
	 	(i) 	
      the Purchaser 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 Purchaser contained herein, the
      Questionnaire or in any other document furnished by the Purchaser to the
      Company in connection herewith, being untrue in any material respect or
      any breach or failure by the Purchaser to comply with any covenant or
      agreement made by the Purchaser to the Company in connection
  therewith;

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 8 of 11 

	 	(j) 	
      the issuance and sale of the Purchased Securities to the
      Purchaser will not be completed if it would be unlawful or if, in the
      discretion of the Company acting reasonably, it is not in the best
      interests of the Company;

	 	 	 
	 	(k) 	
      the Purchaser has been advised to consult its own legal,
      tax and other advisors with respect to the merits and risks of an
      investment in the Purchased Securities and with respect to applicable
      resale restrictions and it is solely responsible (and the Company is in
      any way responsible) for compliance with applicable resale
      restrictions;

	 	 	 
	 	(l) 	
      the Securities are not listed on any stock exchange or
      automated dealer quotation system and no representation has been made to
      the Purchaser that any of the Securities will become listed on any stock
      exchange or automated dealer quotation system;

	 	 	 
	 	(m) 	
      neither the SEC nor any other securities commission or
      similar regulatory authority has reviewed or passed on the merits of the
      Securities ;

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

	 	 	 
	 	(o) 	
      there is no government or other insurance covering any of
      the Securities; and

	 	 	 
	 	(p) 	
      this Subscription Agreement is not enforceable by the
      Purchaser unless it has been accepted by the Company, and the Purchaser
      acknowledges and agrees that the Company reserves the right to reject any
      Subscription for any reason.

2.2         
Representations by the purchaser

The Purchaser represents and warrants to the Issuer that, as at
the Agreement Date and at the Closing:

	 	(q) 	
      the Purchaser is resident in the United States;

	 	 	 
	 	(r) 	
      the Purchaser has received and carefully read this
      Subscription Agreement;

	 	 	 
	 	(s) 	
      the Purchaser 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 Purchaser 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
      Purchaser;

	 	 	 
	 	(t) 	
      the Purchaser (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 Purchased
      Securities for an indefinite period of time, and can afford the complete
      loss of such investment;

	 	 	 
	 	(u) 	
      the Purchaser is aware that an investment in the Company
      is speculative and involves certain risks, including the possible loss of
      the investment;

	 	 	 
	 	(v) 	
      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 Purchaser, or of any
      agreement, written or oral, to which the Purchaser may be a party or by
  which the Purchaser is or may be bound;

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 9 of 11 

	 	(w) 	
      the Purchaser has duly executed and delivered this
      Subscription Agreement and it constitutes a valid and binding agreement of
      the Purchaser enforceable against the Purchaser;

	 	 	 
	 	(x) 	
      the Purchaser 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 Purchased Securities and the
      Company, and the Purchaser is providing evidence of such knowledge and
      experience in these matters through the information requested in the
      Questionnaire;

	 	 	 
	 	(y) 	
      the Purchaser 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 Purchaser
      shall promptly notify the Company;

	 	 	 
	 	(z) 	
      all information contained in the Questionnaire is
      complete and accurate and may be relied upon by the Company, and the
      Purchaser will notify the Company immediately of any material change in
      any such information occurring prior to the closing of the purchase of the
      Securities ;

	 	 	 
	 	(aa) 	
      the Purchaser is purchasing the Purchased Securities 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
      Purchased Securities, and the Purchaser has not subdivided his interest in
      the Purchased Securities with any other person;

	 	 	 
	 	(bb) 	
      the Purchaser is not an underwriter of, or dealer in, the
      common shares of the Company, nor is the Purchaser participating, pursuant
      to a contractual agreement or otherwise, in the distribution of the
      Securities ;

	 	 	 
	 	(cc) 	
      the Purchaser has made an independent examination and
      investigation of an investment in the Purchased Securities 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 Purchaser's decision to invest in the Purchased Securities and the
      Company;

	 	 	 
	 	(dd) 	
      if the Purchaser is acquiring the Purchased Securities as
      a fiduciary or agent for one or more investor accounts, the investor
      accounts for which the Purchaser 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;

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

	 	 	 
	 	(ff) 	
      the Purchaser is not aware of any advertisement of any of
      the Purchased Securities and is not acquiring the Purchased Securities 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

	 	 	 
	 	(gg) 	
      no person has made to the Purchaser any written or oral
      representations:

	 	 	 
	 		
      (i) 
	that any person will resell or repurchase any of the
      Securities ;

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 10 of 11 

	 	(ii) 	
      that any person will refund the purchase price of any of
      the Securities ;

	 	 	 
	 	(iii) 	
      as to the future price or value of any of the Securities;
      or

	 	 	 
	 	(iv) 	
      that any of the Securities 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 Securities of the
      Company on any stock exchange or automated dealer quotation
  system.

2.3        
 Reliance, indemnity and notification of changes

The representations and warranties in the Subscription
Agreement (including the first (cover) page, the Terms, the General Provisions
and the other schedules and appendices incorporated by reference) are made by
the Purchaser with the intent that they be relied upon by the Issuer in
determining its suitability as a purchaser of Purchased Securities, and the
Purchaser hereby agrees to indemnify the Issuer against all losses, claims,
costs, expenses and damages or liabilities which any of them may suffer or incur
as a result of reliance thereon. The Purchaser undertakes to notify the Issuer
immediately of any change in any representation, warranty or other information
relating to the Purchaser set forth in the Subscription Agreement (including the
first (cover) page, the Terms, the General Provisions and the other schedules
and appendices incorporated by reference) which takes place prior to the
Closing.

2.4         
Survival of representations and warranties

The representations and warranties contained in this Section
will survive the Closing.

3.           
ISSUER’S ACCEPTANCE

The Subscription Agreement, when executed by the Purchaser, and
delivered to the Issuer, will constitute a subscription for Purchased Securities
which will not be binding on the Issuer until accepted by the Issuer by
executing the Subscription Agreement in the space provided on the face page(s)
of the Agreement and, notwithstanding the Agreement Date, if the Issuer accepts
the subscription by the Purchaser, the Subscription Agreement will be entered
into on the date of such execution by the Issuer.

4.           
CLOSING

4.1          On or
before the end of the fifth business day before the Closing Date, the Purchaser
will deliver to the Issuer the Subscription Agreement and all applicable
schedules and required forms, duly executed, and payment in full for the total
price of the Purchased Securities to be purchased by the Purchaser.

4.2          At
Closing, the Issuer will deliver to the Purchaser the certificates representing
the Purchased Securities purchased by the Purchaser registered in the name of
the Purchaser or its nominee, or as directed by the Purchaser.

5.           
MISCELLANEOUS

5.1          The
Purchaser agrees to sell, assign or transfer the Securities only in accordance
with the requirements of applicable securities laws and any legends placed on
the Securities as contemplated by the Subscription Agreement.

5.2          The
Purchaser hereby authorizes the Issuer to correct any minor errors in, or
complete any minor information missing from any part of the Subscription
Agreement and any other schedules, forms, certificates or documents executed by
the Purchaser and delivered to the Issuer in connection with the Private
Placement.

5.3          The
Issuer may rely on delivery by fax machine of an executed copy of this
subscription, and acceptance by the Issuer of such faxed copy will be equally
effective to create a valid and binding agreement between the Purchaser and the
Issuer in accordance with the terms of the Subscription Agreement.

	Subscription Agreement (with related appendices,
      schedules and forms) 	Page 11 of 11 

5.4         
Without limitation, this subscription and the transactions contemplated by this
Subscription Agreement are conditional upon and subject to the Issuer’s having
obtained such regulatory approval of this subscription and the transactions
contemplated by this Subscription Agreement as the Issuer considers
necessary.

5.5          This
Subscription Agreement is not assignable or transferable by the parties hereto
without the express written consent of the other party to this Subscription
Agreement.

5.6          Time
is of the essence of this Subscription Agreement.

5.7         
Except as expressly provided in this Subscription Agreement and in the
agreements, instruments and other documents contemplated or provided for in this
Subscription Agreement, this Subscription Agreement contains the entire
agreement between the parties with respect to the Securities and there are no
other terms, conditions, representations or warranties whether expressed,
implied, oral or written, by statute, by common law, by the Issuer, or by anyone
else.

5.8          The
parties to this Subscription Agreement may amend this Subscription Agreement
only in writing.

5.9          This
Subscription Agreement enures to the benefit of and is binding upon the parties
to this Subscription Agreement and their successors and permitted assigns.

5.10          A
party to this Subscription Agreement will give all notices to or other written
communications with the other party to this Subscription Agreement concerning
this Subscription Agreement by hand or by registered mail addressed to the
address given on page 1.

5.11          This
Subscription Agreement is to be read with all changes in gender or number as
required by the context.

5.12          This
Subscription Agreement will be governed by and construed in accordance with the
internal laws of Nevada (without reference to its rules governing the choice or
conflict of laws), and the parties hereto irrevocably attorn and submit to the
exclusive jurisdiction of the courts of Nevada with respect to any dispute
related to this Subscription Agreement.

End of General Provisions

End of Subscription Agreement

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