Document:

Exhibit 4.1

 

THIS WARRANT AND THE COMMON SHARES ISSUABLE
UPON EXERCISE OF THIS WARRANT HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”)
OR ANY STATE SECURITIES LAWS. NEITHER THIS WARRANT NOR THE COMMON SHARES ISSUABLE UPON EXERCISE OF THIS WARRANT MAY BE SOLD, PLEDGED,
HYPOTHECATED OR OTHERWISE TRANSFERRED UNLESS THE WARRANT AND/OR THE COMMON SHARES ISSUABLE UPON EXERCISE HEREOF HAVE BEEN REGISTERED
UNDER THE SECURITIES ACT AND ANY APPLICABLE STATE SECURITIES LAWS OR UNLESS AN EXEMPTION FROM SUCH REGISTRATION IS AVAILABLE AND
THE COMPANY RECEIVES AN OPINION OF COUNSEL IN FORM AND SUBSTANCE REASONABLY SATISFACTORY TO IT TO SUCH EFFECT. 

 

	 	Right to Purchase [*] Common Shares of Chanticleer
    Holdings, Inc. (subject to adjustment as provided herein)

 

COMMON STOCK WARRANT

 

Series 2014

 

Issue Date: January [*], 2015

 

CHANTICLEER HOLDINGS,
INC., a corporation organized under the laws of the State of Delaware (the “Company”), hereby certifies
that _____________ or its permitted assigns (the “Holder”), is entitled, subject to the terms set forth below
to purchase from the Company at any time after the issue date of this Warrant (the “Issue Date”) until 5:00
p.m., Eastern Standard Time on January _____, 2020, (the “Expiration Date”), ________ ([*]) fully paid and
non-assessable Common Shares (as hereinafter defined) of the Company at a per share purchase price of two dollars and fifty
cents (USD $2.50). The purchase price per share, as adjusted from time to time as herein provided, is referred to herein as the
“Purchase Price.” The number and character of such Common Shares and the Purchase Price are subject to adjustment
as provided herein. This Warrant is being issued to the Holder pursuant to the terms and conditions of that certain Subscription
Agreement of even date herewith by and between the Company and the Holder (the “Subscription Agreement”). All
terms not otherwise defined herein shall have the same meaning as in the Subscription Agreement.

 

As used herein the
following terms, unless the context otherwise requires, have the following respective meanings:

 

A.           The
term “Business Day” shall mean any day except Saturday, Sunday, any day which shall be a federal legal holiday
in the United States or any day on which banking institutions in the State of Delaware are authorized or required by law or other
governmental action to close.

 

B.           The
term “Company” shall include Chanticleer Holdings, Inc. and any corporation which shall succeed or assume the
obligations of Chanticleer Holdings, Inc. hereunder.

 

C.           The
term “Common Shares” includes (a) the Company’s Common Shares, $.0001 par value per share, as authorized
on the date hereof, and (b) any other securities into which or for which any of the securities described in (a) may be converted
or exchanged pursuant to a plan of recapitalization, reorganization, merger, sale of assets or otherwise.

 

    	 

    	 

    

 

D.           “Market
Price” means the average of the lowest three (3) Trading Prices for the Common Stock during the ten (10) Trading Day
period ending on the last complete Trading Day prior to the Conversion Date.

 

E.           The
term “Note” refers to that certain 8% Convertible Promissory Note in the principal amount of $________ of even
date herewith from the Company to the Holder which was issued and sold pursuant to terms of the Subscription Agreement.

 

F.           The
term “Other Securities” refers to any stock (other than Common Shares) and other securities of the Company or
any other person (corporate or otherwise) which the Holder of the Warrant at any time shall be entitled to receive, or shall have
received, on the exercise of the Warrant, in lieu of or in addition to Common Shares, or which at any time shall be issuable or
shall have been issued in exchange for or in replacement of Common Shares or Other Securities pursuant to Section 2 herein or otherwise.

 

G.           “Trading
Day” means a day on which the principal market or exchange, on which the Common Shares are listed or quoted for trading,
is open (e.g. the Nasdaq Capital Market, the NYSE AMEX Equities Exchange, the New York Stock Exchange, the OTC Bulletin Board or
the Pink Sheets as operated by Pink OTC Markets, etc.).

 

H.           “Trading
Price” means the closing bid price of the Common Shares on The Nasdaq Stock Exchange or if The Nasdaq Stock Exchange
is not the principal trading market for such security, the closing bid price of the Common Shares on the principal securities exchange
or trading market where the Company Shares are listed or traded or, if no closing bid price of the Common Shares is available in
any of the foregoing manners, the average of the closing bid prices of any market makers for the Common Shares on the OTC Markets.

 

I.           The
term “Warrant Shares” shall mean the Common Shares issuable upon exercise of this Warrant.

 

J.           The
term “Registration Rights Agreement” shall mean the Registration Rights Agreement of even date herewith by and
between the Company and the Holder pursuant to which the Company is obligated to register the resale of the Warrant Shares.

 

1.           Exercise
of Warrant.

 

1.1           Number
of Shares Issuable upon Exercise. From and after the Issue Date through and including the Expiration Date, the Holder hereof
shall be entitled to receive, upon exercise of this Warrant in whole in accordance with the terms of subsection 1.2 or upon
exercise of this Warrant in part in accordance with subsection 1.3, Common Shares of the Company, subject to adjustment pursuant
to Section 3.

 

1.2.          Full
Exercise. This Warrant may be exercised in full by the Holder hereof by delivery of an original or facsimile copy of the form
of subscription attached as Exhibit A hereto (the “Subscription Form”) duly executed by such Holder and
simultaneously surrender of the original Warrant to the Company at its principal office, accompanied by payment, in cash, wire
transfer or by certified or official bank check payable to the order of the Company, in the amount obtained by multiplying the
number of Common Shares for which this Warrant is then exercisable by the Purchase Price then in effect.

 

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1.3.          Partial
Exercise. This Warrant may be exercised in part (but not for a fractional share) by surrender of this Warrant in the manner
and at the place provided in subsection 1.2 except that the amount payable by the Holder on such partial exercise shall be
the amount obtained by multiplying (a) the number of whole shares designated by the Holder in the Subscription Form by (b) the
Purchase Price then in effect. On any such partial exercise, the Company, at its expense, will forthwith issue and deliver to or
upon the order of the Holder hereof a new Warrant of like tenor, in the name of the Holder hereof or as such Holder (upon payment
by such Holder of any applicable transfer taxes) may request, the whole number of Common Shares for which such Warrant may still
be exercised.

 

1.4.          Company
Acknowledgment; Issuance Taxes. The Company will, at the time of the exercise of the Warrant, upon the request of the Holder
hereof acknowledge in writing its continuing obligation to afford to such Holder any rights to which such Holder shall continue
to be entitled after such exercise in accordance with the provisions of this Warrant. The issuance of certificates for Common Shares
upon the exercise of this Warrant will be made without charge to the Holder for any issuance tax in respect thereof or any other
cost incurred by the Company in connection with such exercise and related transfer of the shares; provided, however, that
the Company shall not be required to pay any tax that may be payable in respect of any transfer involved in the issuance and delivery
of any certificate or instrument in a name other than that of the Holder of this Warrant, and that the Company shall not be required
to issue or deliver any such certificate or instrument unless and until the person or persons requiring the issue thereof shall
have paid to the Company the amount of such tax or shall have established to the satisfaction of the Company that such tax has
been paid.

 

1.5.          Delivery
of Stock Certificates, etc. on Exercise. The Company agrees that the Common Shares purchased upon exercise of this Warrant
shall be deemed to be issued to the Holder hereof as the record owner of such shares as of the close of business on the date on
which this Warrant shall have been surrendered and payment made for such shares as aforesaid. Within two (2) Business Days thereafter
(the “Deadline”), the Company at its expense will cause to be issued in the
name of and delivered to the Holder hereof, or as such Holder (upon payment by such Holder of any applicable transfer taxes) may
direct in compliance with applicable securities laws, a certificate or certificates for the number of duly and validly issued,
fully paid and non-assessable Common Shares (or Other Securities) to which such Holder shall be entitled on such exercise, plus,
in lieu of any fractional share to which such Holder would otherwise be entitled, cash equal to such fraction multiplied by the
closing market price of the Common Stock on the exercise date of one full Common Share, together with any other stock or other
securities and property (including cash, where applicable) to which such Holder is entitled upon such exercise pursuant to Section 1
or otherwise. If the Holder shall have given exercised all or any portion of this Warrant in accordance with its terms, the Company’s
obligation to issue and deliver the certificates for Common Shares shall be absolute and unconditional, irrespective of the absence
of any action by the Holder to enforce the same, any waiver or consent with respect to any provision thereof, the recovery of any
judgment against any person or any action to enforce the same, any failure or delay in the enforcement of any other obligation
of the Company to the holder of record, or any setoff, counterclaim, recoupment, limitation or termination, or any breach or alleged
breach by the Holder of any obligation to the Company, and irrespective of any other circumstance which might otherwise limit such
obligation of the Company to the Holder in connection with such conversion. 

 

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1.6           Delivery
of Common Shares by Electronic Transfer. In lieu of delivering physical certificates representing the Common Shares issuable
upon the exercise of this Warrant, provided the Company is participating in the Depository Trust Company (“DTC”)
Fast Automated Securities Transfer (“FAST”) program, upon request of the Holder the Company shall use its best
efforts to cause its transfer agent to electronically transmit the Common Shares issuable upon exercise of this Warrant to the
Holder by crediting the account of Holder’s Prime Broker with DTC through its Deposit Withdrawal Agent Commission (“DWAC”)
system.

 

1.7           Failure
to Deliver Common Shares Prior to Deadline. Without in any way limiting the Holder’s right to pursue other remedies,
including actual damages and/or equitable relief, the parties agree that if delivery of the Common Shares issuable upon exercise
of this Warrant is not delivered by the Deadline, the Company shall pay to the Holder $2,000 per day in cash, for each day beyond
the Deadline that the Company fails to deliver such Common Shares. Such cash amount shall be paid to Holder by the fifth day of
the month following the month in which it has accrued. The Company agrees that the right to exercise this Warrant is a valuable
right to the Holder. The damages resulting from a failure, attempt to frustrate, interference with such exercise right are difficult
if not impossible to qualify. Accordingly the parties acknowledge that the liquidated damages provision contained in this Section
1.7 are justified.

 

1.8           Cashless
Exercise of the Warrant. In the event (i) the Company should fail to register (and maintain such registration) the Warrant
Shares as required by the Registration Rights Agreement, (ii) breach any term of the Registration Rights Agreement, or (iii) upon
an Event of Default (as that term is defined in the Note) under the Note, then in lieu of exercising the Warrant by paying the
Purchase Price in cash, the Warrant may be exercised in whole at any time or in part from time to time prior to the Expiration
Date of the Warrant, by the Holder by surrendering the Warrant to the Company, without payment of any other consideration, together
with a duly executed Subscription Notice. The number of Common Shares to be issued by the Company shall be calculated using the
following formula:

 

	 	X	=	Y(A-B)
	 	 	 	     A
	 	 	 	 
	Where	X	=	the number of Common Shares to be issued to the Holder
	 	 	 	 
	 	Y	=	the number of Common Shares purchasable under the Warrant or, if the Warrant is being exercised in part, under the portion of the Warrant being exercised (at the date of surrender of the Warrant and the notice of exercise)
	 	 	 	 
	 	A	=	the Market Price (at the date of surrender and the notice of exercise)
	 	 	 	 
	 	B	=	the per share Purchase Price (as adjusted to the date of surrender of the Warrant and the notice of exercise) this Warrant shall become immediately exercisable by the Holder on a cashless basis.

 

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For purposes of Rule 144 promulgated under
the Securities Act, it is intended, understood and acknowledged that the Common Shares issued in a cashless exercise transaction
shall be deemed to have been acquired by the Holder, and the holding period for the Common Shares shall be deemed to have commenced,
on the date this Warrant was originally issued to the Holder.

 

1.9           The
registration rights for the Common Shares underlying the Warrant are as set forth in the Registration Rights Agreement. Unless
the Company shall have registered the Common Shares underlying this Warrant, the Common Shares issuable upon the exercise of this
Warrant will be “restricted securities” as that term is defined in the Securities Act. The Company may insert the following
or similar legend on the face of the certificates evidencing such securities if required in compliance with state securities laws:

 

"These securities have
not been registered under any state securities laws and may not be sold or otherwise transferred or disposed of except pursuant
to an effective registration statement under any applicable state securities laws, or an opinion of counsel satisfactory to counsel
to Chanticleer Holdings, Inc. that an exemption from registration under any applicable state securities laws is available."

 

2.           Adjustment
for Reorganization, Consolidation, Merger, etc.

 

2.1.          Reorganization,
Consolidation, Merger, etc. In case at any time or from time to time, the Company shall (a) effect a reorganization, (b) consolidate
with or merge into any other person or (c) transfer all or substantially all of its properties or assets to any other person,
then, in each such case, as a condition to the consummation of such a transaction, proper and adequate provision shall be made
by the Company whereby the Holder of this Warrant, on the exercise hereof as provided in Section 1, at any time after the
consummation of such reorganization, consolidation or merger or sale, as the case may be, shall receive, in lieu of the Common
Shares (or Other Securities) issuable on such exercise prior to such consummation, the stock and other securities and property
(including cash) to which such Holder would have been entitled upon such consummation, if such Holder had so exercised this Warrant,
immediately prior thereto, all subject to further adjustment thereafter as provided in Section 3.

 

2.2.          Continuation
of Terms. Upon any reorganization, consolidation, merger or transfer (and any dissolution following any transfer) referred
to in this Section 2, this Warrant shall continue in full force and effect and the terms hereof shall be applicable to the
Other Securities and property receivable on the exercise of this Warrant after the consummation of such reorganization, consolidation
or merger following any such transfer, as the case may be, and shall be binding upon the issuer of any Other Securities, including,
in the case of any such transfer, the person acquiring all or substantially all of the properties or assets of the Company, whether
or not such person shall have expressly assumed the terms of this Warrant as provided in Section 3.

 

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3.          Extraordinary
Events Regarding Common Stock. In the event that the Company shall (a) issue additional Common Shares as a dividend or
other distribution on outstanding Common Shares, (b) subdivide its outstanding Common Shares, or (c) combine its outstanding
Common Shares into a smaller number of Common Shares, then, in each such event, the Purchase Price shall, simultaneously with the
happening of such event, be adjusted by multiplying the then Purchase Price by a fraction, the numerator of which shall be the
number of Common Shares outstanding immediately prior to such event and the denominator of which shall be the number of Common
Shares outstanding immediately after such event, and the product so obtained shall thereafter be the Purchase Price then in effect.
The Purchase Price, as so adjusted, shall be readjusted in the same manner upon the happening of any successive event or events
described herein in this Section 3. The number of Common Shares that the Holder of this Warrant shall thereafter, on the exercise
hereof as provided in Section 1, be entitled to receive shall be adjusted to a number determined by multiplying the number
of Common Shares that would otherwise (but for the provisions of this Section 3) be issuable on such exercise by a fraction
of which (a) the numerator is the Purchase Price that would otherwise (but for the provisions of this Section 3) be in
effect, and (b) the denominator is the Purchase Price in effect on the date of such exercise.

 

4.          Certificate
as to Adjustments. In each case of any adjustment or readjustment in the Common Shares (or Other Securities) issuable on the
exercise of the Warrants, the Company at its expense will promptly cause its Chief Financial Officer or other appropriate designee
to compute such adjustment or readjustment in accordance with the terms of the Warrant and prepare a certificate setting forth
such adjustment or readjustment and showing in detail the facts upon which such adjustment or readjustment is based, including
a statement of (a) the consideration received or receivable by the Company for any additional Common Shares (or Other Securities)
issued or sold or deemed to have been issued or sold, (b) the number of Common Shares (or Other Securities) outstanding or
deemed to be outstanding, and (c) the Purchase Price and the number of Common Shares to be received upon exercise of this
Warrant, in effect immediately prior to such adjustment or readjustment and as adjusted or readjusted as provided in this Warrant.
The Company will forthwith mail a copy of each such certificate to the Holder of the Warrant.

 

5.          Reservation
of Stock, etc. Issuable on Exercise of Warrant. The Company will at all times reserve and keep available, solely for issuance
and delivery on the exercise of the Warrants, all Common Shares (or Other Securities) from time to time issuable on the exercise
of the Warrant.

 

6.          Assignment;
Exchange of Warrant. Subject to compliance with applicable securities laws, this Warrant, and the rights evidenced hereby,
may be transferred by any registered holder hereof (a “Transferor”). On the surrender for exchange of this Warrant,
with the Transferor’s endorsement in the form of Exhibit B attached hereto (the “Transferor Endorsement Form”)
and together with an opinion of counsel reasonably satisfactory to the Company that the transfer of this Warrant will be in compliance
with applicable securities laws, the Company at its expense, but with payment by the Transferor of any applicable transfer taxes,
will issue and deliver to or on the order of the Transferor thereof a new Warrant or Warrants of like tenor, in the name of the
Transferor and/or the transferee(s) specified in such Transferor Endorsement Form (each a “Transferee”), calling
in the aggregate on the face or faces thereof for the number of Common Shares called for on the face or faces of the Warrant so
surrendered by the Transferor. No such transfers shall result in a public distribution of the Warrant.

 

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7.          Replacement
of Warrant. On receipt of evidence reasonably satisfactory to the Company of the loss, theft, destruction or mutilation of
this Warrant and, in the case of any such loss, theft or destruction of this Warrant, on delivery of an indemnity agreement or
security reasonably satisfactory in form and amount to the Company or, in the case of any such mutilation, on surrender and cancellation
of this Warrant, the Company at its expense, will execute and deliver, in lieu thereof, a new Warrant of like tenor.

 

8.          Transfer
on the Company’s Books. The Company shall register this Warrant, upon records to be maintained by the Company for that
purpose (the “Warrant Register”), in the name of the Record Holder hereof from time to time. Until this Warrant
is transferred on the books of the Company, the Company may treat the registered holder hereof as the absolute owner hereof for
all purposes, notwithstanding any notice to the contrary.

 

9.          Notices.
All notices, demands, requests, consents, approvals, and other communications required or permitted hereunder shall be in writing
and, unless otherwise specified herein, shall be (i) personally served, (ii) deposited in the mail, registered or certified, return
receipt requested, postage prepaid, (iii) delivered by reputable air courier service with charges prepaid, or (iv) transmitted
by hand delivery, telegram, or facsimile, addressed as set forth below or to such other address as such party shall have specified
most recently by written notice. Any notice or other communication required or permitted to be given hereunder shall be deemed
effective (a) upon hand delivery or delivery by facsimile, with accurate confirmation generated by the transmitting facsimile machine,
at the address or number designated below (if delivered on a business day during normal business hours where such notice is to
be received), or the first business day following such delivery (if delivered other than on a business day during normal business
hours where such notice is to be received) or (b) on the second business day following the date of mailing by express courier service,
fully prepaid, addressed to such address, or upon actual receipt of such mailing, whichever shall first occur or (c) three business
days after deposited in the mail if delivered pursuant to subsection (ii) above. The addresses for such communications shall be:
(i) if to the Company to: 7621 Little Avenue, Suite 414, Charlotte, NC  28226, facsimile number (704) 366-2463; and (ii)
if to the Holder to: the address set forth on the Holder’s signature page to the Subscription Agreement. The Company and
the Holder may change their respective addresses for notices by like notice to the other party.

 

10.         Miscellaneous.
This Warrant and any term hereof may be changed, waived, discharged or terminated only by an instrument in writing signed by the
party against which enforcement of such change, waiver, discharge or termination is sought. The headings in this Warrant are for
purposes of reference only, and shall not limit or otherwise affect any of the terms hereof. The invalidity or unenforceability
of any provision hereof shall in no way affect the validity or enforceability of any other provision.

 

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11.         Governing
Law; Venue. This Warrant shall be governed by and construed in accordance with the domestic laws of the State of New York,
without giving effect to any choice or conflict of law provision or rule. The parties further: (i) agree that any legal suit, action
or proceeding arising out of or relating to this Note shall be instituted exclusively in any Federal or State court of competent
jurisdiction within the State of New York, County of New York, (ii) waive any objection that they may have now or hereafter to
the venue of any such suit, action or proceeding, and (iii) irrevocably consent to the in personam jurisdiction of
any Federal or State court of competent jurisdiction within the State of New York, County of New York in any such suit, action
or proceeding. The parties each further agree to accept and acknowledge service of any and all process which may be served in any
such suit, action or proceeding in a Federal or State court of competent jurisdiction within the State of New York, County of New
York, and that service of process upon the parties mailed by certified mail to their respective addresses shall be deemed in every
respect effective service of process upon the parties, in any action or proceeding.

 

12.         Legal
Fees. In the event that Holder is required to take legal or other action to enforce its rights or obtain collection under this
Warrant, the Company shall pay the Holder hereof reasonable costs of collection, or enforcement of the terms hereof, including
reasonable attorneys’ fees.

 

[SIGNATURE PAGE FOLLOWS]

 

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IN WITNESS WHEREOF, the
Company has executed this Warrant as of the date first written above.

 

	 	CHANTICLEER HOLDINGS, INC.
	 	 	 
	 	By:	 
	 	 	 
	 	Name:	Michael D. Pruitt
	 	 	 
	 	Title:	Chief Executive Officer

 

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Exhibit A

 

FORM OF SUBSCRIPTION

(to be signed only on exercise of Warrant)

 

TO: CHANTICLEER HOLDINGS, INC.

 

The undersigned, pursuant to the provisions
set forth in the attached Warrant, hereby irrevocably elects to purchase:

 

 ̈          ____________
Common Shares covered by such Warrant, for a total purchase price of $____________, payable _______________________.

 

The undersigned herewith makes payment
of the full purchase price for such shares at the price per share provided for in such Warrant, which is $____________. Such payment
takes the form of (check applicable box or boxes):

 

 ̈          $____________
in lawful money of the United States, paid by check.

 

 ̈          $____________
in lawful money of the United States, paid by wire transfer.

 

The undersigned requests that the
certificates for such shares be issued in the name of, and delivered to _____________________________________________________
whose address is_____________________________
________________________________________________________________________________________________
______________________________________________________________

 

YOU MUST COMPLETE THE ACCREDITED INVESTOR
CERTIFICATION FOUND ON APPENDIX A HERETO AND CHECK AT LEAST ONE APPROPRIATE BOX CERTIFYING YOUR STATUS AS AN ACCREDITED INVESTOR
IN ORDER TO EXERCISE THIS WARRANT.

 

Payment for Common
Shares. If the undersigned has delivered to the Company, with this Subscription, a check payable to the Company in the amount
of the Purchase Price of the Common Shares, if the Warrant is not being exercised on a cashless basis pursuant to the provisions
of Section 1.8,, then the undersigned warrants that such check is backed by good and sufficient funds and authorizes the Company
to deposit that check immediately upon receipt of this Subscription. If such a check has not been delivered with this Subscription,
then the undersigned agrees to immediately deliver the amount of the Purchase Price of the Common Shares to the Company, in immediately
available funds in the form of a wire transfer using the following instructions:

 

	To:	_____________________
	 	_____________________
	 	_____________________
	 	Attention:  ____________
	 	Telephone: ____________
	Routing Number:	______________________
	For Further Credit to:	______________________
	 	______________________
	 	______________________
	Account Number:	______________________
	 	FBO: _________________
	 	(Subscriber’s Name)

 

    	 

    	 

    

 

Information.
The undersigned acknowledges that the undersigned has been offered the opportunity to obtain information, to verify the accuracy
of the information received by the undersigned, to evaluate the merits and risks of this investment and to ask questions and receive
satisfactory answers concerning the terms and conditions of this investment. The undersigned has reviewed the Company’s filings
with the Securities and Exchange Commission (the “SEC”). The Company has made its officers available to the
undersigned to answer questions concerning the Company and the investment being made hereby. In making the decision to purchase
the Common Shares, the undersigned has relied and will rely solely upon independent investigations made by the undersigned. The
undersigned is not relying on the Company with respect to any tax or other economic considerations involved in this investment.
The undersigned has been encouraged by the Company to consult with the undersigned’s own attorneys and other advisors with
respect to all matters concerning this investment, has been given adequate opportunity to so consult, and has done so to the extent
the undersigned has deemed appropriate.

 

Accredited Investor
and other Investment Representations. The undersigned represents and warrants that the undersigned is an “accredited
investor” as defined in Rule 501(a) of Regulation D under the Securities Act.

 

	Dated:	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	(Signature must conform to name of holder as specified on the face of the Warrant.)
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	(Address)

 

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Exhibit B

 

FORM OF TRANSFEROR ENDORSEMENT

(To be signed only on transfer of Warrant)

 

For value received,
the undersigned hereby sells, assigns, and transfers unto the person(s) named below under the heading “Transferees”
the right represented by the within Warrant to purchase the percentage and number of Common Shares of CHANTICLEER HOLDINGS, INC.
to which the within Warrant relates specified under the headings “Percentage Transferred” and “Number Transferred,”
respectively, opposite the name(s) of such person(s) and appoints each such person Attorney to transfer its respective right on
the books of CHANTICLEER HOLDINGS, INC. with full power of substitution in the premises.

 

	Transferees	Percentage Transferred	Number Transferred
	 	 	 
	 	 	 
	 	 	 

 

	Dated:  ______________, _______	 	 
	 	 	(Signature must conform to name of holder as specified on the face of the Warrant)
	 	 	 
	Signed in the presence of:	 	 
	 	 	 
	 	 	 
	(Name)	 	 
	 	 	(address)
	 	 	 
	The undersigned transferee acknowledges and agrees that this transfer may only be made in compliance with applicable federal and state securities laws, and in accordance with Section 6 of the warrant.

                                              
	 	 
	 
	 
	(address)
	 	 	 
	ACCEPTED AND AGREED:	 	 
	[TRANSFEREE]	 	 
	 	 	 
	 	 	 
	(Name)Exhibit 10.1

 

SUBSCRIPTION
AGREEMENT

 

hotr convertible
Securities

 

SUBSCRIPTION AGREEMENT
(this “Agreement” or “Subscription Agreement”) dated as of January ___, 2015 between
CHANTICLEER HOLDINGS, INC., a Delaware corporation having its principal offices at 7621 Little Avenue, Suite 414, Charlotte, NC
28226 (the “Company”) and ____________ (“Subscriber”), whose name and address are as set
forth on the Signature Page to this Agreement.

 

WHEREAS, on
the terms and subject to the conditions hereinafter set forth, the Company is offering (the “Offering”) units,
with each such unit consisting of an 8% convertible note in the principal amount of Fifty Thousand Dollars ($50,000) in the form
attached hereto as Exhibit A and incorporated herein by such reference (the “Note”) and a common stock
purchase warrant to purchase twelve thousand five hundred (12,500) shares of the Company’s common stock, par value $0.0001
per share (the “Common Stock”) exercisable at two dollars and fifty cents ($2.50) per share for a period of
up to five (5) years from the issuance date in the form attached hereto as Exhibit B and incorporated herein by such reference
(the “Warrants”). The Unit is being offered to the Subscriber who has advised the Company that it qualifies
as an “accredited investor” as defined in Rule 501 of Regulation D (“Regulation D”) promulgated
under the Securities Act of 1933, as amended (the “Securities Act”). The Note and Warrant are sometimes hereinafter
referred to as the “Securities.”

 

WHEREAS, the
Subscriber has received and carefully read this Subscription Agreement, the Note, the Warrant and the
registration rights agreement in the form attached hereto as Exhibit C and incorporated herein by such reference (the “Registration
Rights Agreement”) (collectively, the “Offering Documents”) which, among other things, describe the
terms and conditions by which the Subscriber may invest in the Offering.

 

WHEREAS, Subscriber
desires to acquire the aggregate number of Securities upon the terms and conditions of the Offering Documents.

 

WHEREAS, this
Offering shall close on or before January 30, 2015. The Company may extend the Offering upon approval of its Board of Directors.

 

NOW, THEREFORE,
for and in consideration of the premises and the mutual covenants hereinafter set forth, the parties hereto do hereby agree as
follows:

 

Section
1.           Subscription for Securities. On the terms
and subject to the conditions set forth in the Offering Documents, Subscriber hereby irrevocably subscribes for and agrees to purchase
from the Company the Securities for the purchase price as set forth on the Signature Page to this Agreement (the “Purchase
Price”). The Purchase Price is payable by check made payable to “Chanticleer Holdings, Inc.” contemporaneously
with the execution and delivery of this Subscription Agreement to the Company or by wire transfer to the following coordinates:

  

    	 

    	 

    

 

		RBK:	Paragon Commercial Bank

		ABA:	053112288

		BNF:	Chanticleer Holdings, Inc. Escrow Account

		A/C:	0660563

		Attn:	Rose Auteri or Brenda Pierce, Fax Number (919) 861-1120

 

A closing (the “Closing”)
of the sale of the Securities shall occur contemporaneously with the delivery of this Agreement and the Purchase Price by the Subscriber
to the Company. Promptly following the Closing, a duly executed Note, Warrant and Registration Rights Agreement, together with
a copy of this Agreement signed by the Company will be delivered by the Company to Subscriber.

 

Section
2.           Representations, Warranties and Covenants of Subscriber.
Subscriber hereby represents, warrants and covenants to the Company that:

 

2.1           Subscriber
recognizes that the purchase of the Securities involves a high degree of risk in that (i) an investment in the Company is highly
speculative and only investors who can afford the loss of their entire investment should consider investing in the Securities;
(iii) an investor may not be able to readily liquidate its investment; (iv) transferability of the Securities is limited; and (v)
Subscriber could sustain the loss of its entire investment. Subscriber has reviewed the risk factors set forth in the Company’s
filings with the Securities and Exchange Commission (“SEC”) made in the last twelve months.

 

2.2           Subscriber
is an “accredited investor” as such term is defined in Rule 501(a) of Regulation D promulgated under the Securities
Act, and Subscriber is able to bear the economic risk of an investment in the Securities. In addition, Subscriber has such knowledge
and experience in business and financial matters, including prior investments in non-listed and non-registered securities, as is
necessary in order to evaluate the merits and risks of its investment in the Securities.

 

2.3           Subscriber
acknowledges that the Subscriber has been offered the opportunity to obtain information, to verify the accuracy of the information
received by Subscriber, to evaluate the merits and risks of this investment and to ask questions and receive satisfactory answers
concerning the terms and conditions of this investment. The Company has made its officers available to the undersigned to answer
questions concerning the Company and the investment being made hereby. Subscriber has received and has carefully read and considered
the Use of Proceeds attached hereto as Attachment A (the “Use of Proceeds”), and the Company’s
filings with the SEC for at least the last twelve months. In evaluating the suitability of an investment in the Company, Subscriber
has not relied upon any representations or other information (whether oral or written) received from the Company, its officers,
directors, agents, attorneys, accountants, employees or representatives, except information set forth in this Agreement, the Use
of Proceeds or information that is filed with the SEC or obtained from the Company in order to verify such information.

 

2.4           Subscriber
understands that its purchase of the Securities may have tax consequences and that Subscriber must retain its own professional
advisors to evaluate the tax and other consequences of an investment in the Securities. Subscriber has independently evaluated
the merits of its decision to purchase Securities, and Subscriber confirms that it has been afforded the opportunity to consult
with its business, tax and/or legal counsel in making such decision and has availed itself of that opportunity to the extent deemed
advisable by Subscriber.

 

    	2

    	 

    

 

2.5           Subscriber
acknowledges that the Offering has not been reviewed, endorsed or approved by the SEC and that the Securities are being offered
without registration under the Securities Act in reliance upon the exemption from registration afforded by Section 4(a)(2) of the
Securities Act and Rule 506(b) of Regulation D promulgated thereunder and without registration under any state securities laws.
Subscriber understands that a legend will be affixed to the Securities to the effect that the Securities have not been registered
under the Securities Act or any applicable state securities laws and setting forth or referring to the restrictions on transferability
and sale thereof. Subscriber represents and warrants that all offers and sales by Subscriber of the Securities shall be made pursuant
to registration thereof under the Securities Act, or pursuant to an exemption from registration under the Securities Act.

 

2.6           Subscriber
is purchasing the Securities and the shares of Common Stock issuable upon conversion of or otherwise
pursuant to the Note (including, without limitation, such additional shares of Common Stock, if any, as are issuable on account
of interest on the Note or otherwise) and upon the exercise of the Warrant (collectively, the “Conversion Shares”)
for Subscriber’s own account for investment purposes only and not with a view to or for sale in connection with, or
for purposes of, any “distribution” thereof within the meaning of Section 2(11) of the Securities Act.

 

2.7           The
Subscriber acknowledges that it may not withdraw this subscription. Subscriber understands that the Company reserves the right
to reject or limit any subscription in its sole discretion. Subscriber further understands that the Company shall not have any
obligation to sell any Securities in any jurisdiction in which the sale of Securities would constitute a violation of the securities,
“blue sky” or other similar laws of such jurisdiction.

 

2.8           Subscriber’s
address set forth on the signature page hereto is its principal residence if Subscriber is an individual or its principal business
address if Subscriber is a corporation or other entity.

 

2.9           Subscriber
is not subscribing for the Securities as a result of any advertisement, article, notice or other communication published in any
newspaper, magazine or similar media or broadcast over television or radio, or presented at any seminar or general meeting.

 

2.10         Subscriber
has all requisite legal and other power and authority to execute and deliver this Subscription Agreement and to carry out and perform
Subscriber’s obligations hereunder. This Subscription Agreement constitutes a valid and legally binding obligation of Subscriber,
enforceable in accordance with its terms, subject to laws of general application relating to bankruptcy, insolvency and the relief
of debtors and rules of law governing specific performance, injunctive relief or other general principals of equity, whether such
enforcement is considered in a proceeding in equity or law. The funds provided for this investment are either separate property
of Subscriber, community property over which Subscriber has the right of control or are otherwise funds as to which Subscriber
has the sole right of management.

 

    	3

    	 

    

 

2.11         The
execution, delivery and performance of this Subscription Agreement by Subscriber will not result in any violation of, or conflict
with, or constitute a default under, any of Subscriber’s articles of incorporation or by-laws, if applicable, or any agreement
to which Subscriber is a party or by which it is bound.

 

2.12         No
consent from any other person is required in order for Subscriber to execute this Agreement and perform its obligations hereunder,
or such consent has been obtained and a copy has been provided to the Company.

 

2.13         Subscriber
has kept confidential the existence of the Offering and the information contained therein or made available in connection with
any further investigation of the Company.

 

2.14         Subscriber’s
representations and warranties contained in this Subscription Agreement accompanying this Subscription Agreement do not contain
any untrue statement of a material fact. Subscriber understands that the Company is relying upon the truth and accuracy of the
representations, warranties and agreements of Subscriber set forth herein in making its determination that the Offering and sale
of the Securities is exempt from registration under the Securities Act and state securities laws.

 

2.15         Subscriber
has delivered IRS Form W-9 to the Company, or if not a United States citizen, Subscriber has delivered an IRS Form W-8BEN or other
appropriate form to Company.

 

Section 3.             Representation
and Warranties of the Company. The Company represents and warrants to the Buyer that:

 

3.1           Organization
and Qualification. The Company and each of its subsidiaries is a corporation duly organized, validly existing and in good standing
under the laws of the jurisdiction in which it is incorporated, with full power and authority (corporate and other) to own, lease,
use and operate its properties and to carry on its business as and where now owned, leased, used, operated and conducted. The Company
and each of its subsidiaries is duly qualified as a foreign corporation to do business and is in good standing in every jurisdiction
in which its ownership or use of property or the nature of the business conducted by it makes such qualification necessary except
where the failure to be so qualified or in good standing would not have a Material Adverse Effect. “Material Adverse Effect”
means any material adverse effect on the business, operations, assets, financial condition or prospects of the Company or its subsidiaries,
if any, taken as a whole, or on the transactions contemplated hereby or by the agreements or instruments to be entered into in
connection herewith. “Subsidiaries” means any corporation or other organization, whether incorporated or unincorporated,
in which the Company owns, directly or indirectly, any equity or other ownership interest.

 

    	4

    	 

    

 

3.2           Authorization;
Enforcement. (i) The Company has all requisite corporate power and authority to enter into and perform it obligations under
the Offering Documents and to consummate the transactions contemplated hereby and thereby and to issue the Securities, in accordance
with the terms hereof and thereof, (ii) the execution and delivery of the Offering Documents by the Company and the consummation
by it of the transactions contemplated hereby and thereby (including without limitation, the issuance of the Note and the Warrant
and the issuance and reservation for issuance of the Conversion Shares issuable upon conversion or exercise thereof) have been
duly authorized by the Company’s board of directors and no further consent or authorization of the Company, its board of
directors, or its stockholders is required, (iii) the Offering Documents have been duly executed and delivered by the Company by
its authorized representative, and such authorized representative is the true and official representative with authority to sign
the Offering Documents and the other documents executed in connection herewith and bind the Company accordingly, and (iv) this
Agreement constitutes, and upon execution and delivery by the Company of the Note, the Warrant and the Registration Rights Agreement,
each of such instruments will constitute, a legal, valid and binding obligation of the Company enforceable against the Company
in accordance with its terms.

 

3.3           Capitalization.
As of the December 17, 2014, the authorized capital stock of the Company consists of 45,000,000 shares of Common Stock, of which
7,240,333 shares are issued and outstanding. All of such outstanding shares of capital stock are duly authorized, validly issued,
fully paid and non-assessable. No shares of capital stock of the Company are subject to preemptive rights or any other similar
rights of the stockholders of the Company or any liens or encumbrances imposed through the actions or failure to act of the Company.
As of the date of this Agreement, except as set forth in the SEC Documents (as hereinafter defined) (i) there are no outstanding
options, warrants, scrip, rights to subscribe for, puts, calls, rights of first refusal, agreements, understandings, claims or
other commitments or rights of any character whatsoever relating to, or securities or rights convertible into or exchangeable for
any shares of capital stock of the Company or any of its subsidiaries, or arrangements by which the Company or any of its subsidiaries
is or may become bound to issue additional shares of capital stock of the Company or any of its subsidiaries, (ii) there are no
agreements or arrangements under which the Company or any of its subsidiaries is obligated to register the sale of any of its or
their securities under the Securities Act and (iii) there are no anti-dilution or price adjustment provisions contained in any
security issued by the Company (or in any agreement providing rights to security holders) that will be triggered by the issuance
of the Note, the Warrant or the Conversion Shares.

 

3.4           Issuance
of Shares. The Conversion Shares are duly authorized and reserved for issuance and, upon conversion of the Note and the Warrant
in accordance with its respective terms, will be validly issued, fully paid and non-assessable, and free from all taxes, liens,
claims and encumbrances with respect to the issue thereof and shall not be subject to preemptive rights or other similar rights
of stockholders of the Company and will not impose personal liability upon the holder thereof.

 

3.5           Acknowledgment
of Dilution. The Company understands and acknowledges the potentially dilutive effect to the Common Stock upon the issuance
of the Conversion Shares upon conversion of the Note and/or the exercise of the Warrant. The Company further acknowledges that
its obligation to issue Conversion Shares upon conversion of the Note and or the exercise of the Warrant in accordance with this
their respective terms is absolute and unconditional regardless of the dilutive effect that such issuance may have on the ownership
interests of other stockholders of the Company.

 

    	5

    	 

    

 

3.6           No
Conflicts. The execution, delivery and performance of the Offering Documents by the Company and the consummation by the Company
of the transactions contemplated hereby and thereby (including, without limitation, the issuance and reservation for issuance of
the Conversion Shares) will not (i) conflict with or result in a violation of any provision of the Certificate of Incorporation
or By-laws, or (ii) violate or conflict with, or result in a breach of any provision of, or constitute a default (or an event which
with notice or lapse of time or both could become a default) under, or give to others any rights of termination, amendment, acceleration
or cancellation of, any agreement, note, indenture, patent, patent license or instrument to which the Company or any of its subsidiaries
is a party, or (iii) result in a violation of any law, rule, regulation, order, judgment or decree (including federal and state
securities laws and regulations and regulations of any self-regulatory organizations to which the Company or its securities are
subject) applicable to the Company or any of its subsidiaries or by which any property or asset of the Company or any of its subsidiaries
is bound or affected (except for such conflicts, defaults, terminations, amendments, accelerations, cancellations and violations
as would not, individually or in the aggregate, have a Material Adverse Effect). Neither the Company nor any of its subsidiaries
is in violation of its Certificate of Incorporation, By-laws or other organizational documents and neither the Company nor any
of its Subsidiaries is in default (and no event has occurred which with notice or lapse of time or both could put the Company or
any of its subsidiaries in default) under, and neither the Company nor any of its subsidiaries has taken any action or failed to
take any action that would give to others any rights of termination, amendment, acceleration or cancellation of, any agreement,
note, indenture or instrument to which the Company or any of its subsidiaries is a party or by which any property or assets of
the Company or any of its subsidiaries is bound or affected, except for possible defaults as would not, individually or in the
aggregate, have a Material Adverse Effect. The businesses of the Company and its subsidiaries, if any, are not being conducted,
and shall not be conducted so long as the Subscriber owns any of the Securities, in violation of any law, ordinance or regulation
of any governmental entity. Except as specifically contemplated by this Agreement and as required under the Securities Act and
any applicable state securities laws, the Company is not required to obtain any consent, authorization or order of, or make any
filing or registration with, any court, governmental agency, regulatory agency, self regulatory organization or stock market or
any third party in order for it to execute, deliver or perform any of its obligations under the Offering Documents in accordance
with the terms hereof or thereof or to issue and sell the Note and the Warrant in accordance with the terms hereof and to issue
the Conversion Shares upon conversion of the Note and or the exercise of the Warrant. All consents, authorizations, orders, filings
and registrations which the Company is required to obtain pursuant to the preceding sentence have been obtained or effected on
or prior to the date hereof. The Company is not in violation of the continued listing requirements of The Nasdaq Stock Market and
does not reasonably anticipate that the Common Stock will be delisted from The Nasdaq Stock Market in the foreseeable future. The
Company and its subsidiaries are unaware of any facts or circumstances which might give rise to any of the foregoing.

 

    	6

    	 

    

 

3.6           SEC
Documents; Financial Statements. The Company has timely filed all reports, schedules, forms, statements and other documents
required to be filed by it with the SEC pursuant to the reporting requirements of the Securities Exchange Act of 1934, as amended
(the “1934 Act”) (all of the foregoing filed prior to the date hereof and all exhibits included therein and
financial statements and schedules thereto and documents (other than exhibits to such documents) incorporated by reference therein,
being hereinafter referred to herein as the “SEC Documents”). As of their respective dates, the SEC Documents
complied in all material respects with the requirements of the 1934 Act and the rules and regulations of the SEC promulgated thereunder
applicable to the SEC Documents, and none of the SEC Documents, at the time they were filed with the SEC, contained any untrue
statement of a material fact or omitted to state a material fact required to be stated therein or necessary in order to make the
statements therein, in light of the circumstances under which they were made, not misleading. None of the statements made in any
such SEC Documents is, or has been, required to be amended or updated under applicable law (except for such statements as have
been amended or updated in subsequent filings prior the date hereof). As of their respective dates, the financial statements of
the Company included in the SEC Documents complied as to form in all material respects with applicable accounting requirements
and the published rules and regulations of the SEC with respect thereto. Such financial statements have been prepared in accordance
with United States generally accepted accounting principles, consistently applied, during the periods involved and fairly present
in all material respects the consolidated financial position of the Company and its consolidated subsidiaries as of the dates thereof
and the consolidated results of their operations and cash flows for the periods then ended (subject, in the case of unaudited statements,
to normal year-end audit adjustments). Except as set forth in the financial statements of the Company included in the SEC Documents,
the Company has no liabilities, contingent or otherwise, other than (i) liabilities incurred in the ordinary course of business
subsequent to September 30, 2014, and (ii) obligations under contracts and commitments incurred in the ordinary course of business
and not required under generally accepted accounting principles to be reflected in such financial statements, which, individually
or in the aggregate, are not material to the financial condition or operating results of the Company. The Company is subject to
the reporting requirements of the 1934 Act.

 

3.7           Absence
of Certain Changes. Since September 30, 2014, there has been no material adverse change and no material adverse development
in the assets, liabilities, business, properties, operations, financial condition, results of operations, prospects or 1934 Act
reporting status of the Company or any of its subsidiaries.

 

3.8           Absence
of Litigation. Except as set forth in the SEC Documents, there is no action, suit, claim, proceeding, inquiry or investigation
before or by any court, public board, government agency, self-regulatory organization or body pending or, to the knowledge of the
Company or any of its subsidiaries, threatened against or affecting the Company or any of its subsidiaries, or their officers or
directors in their capacity as such, that could have a Material Adverse Effect. The Company and its subsidiaries are unaware of
any facts or circumstances which might give rise to any of the foregoing.

 

    	7

    	 

    

 

3.9           Patents,
Copyrights, etc. The Company and each of its subsidiaries owns or possesses the requisite licenses or rights to use all patents,
patent applications, patent rights, inventions, know-how, trade secrets, trademarks, trademark applications, service marks, service
names, trade names and copyrights (“Intellectual Property”) necessary to enable it to conduct its business as
now operated (and, as presently contemplated to be operated in the future); there is no claim or action by any person pertaining
to, or proceeding pending, or to the Company’s knowledge threatened, which challenges the right of the Company or of a subsidiary
with respect to any Intellectual Property necessary to enable it to conduct its business as now operated (and, as presently contemplated
to be operated in the future); to the best of the Company’s knowledge, the Company’s or its subsidiaries’ current
and intended products, services and processes do not infringe on any Intellectual Property or other rights held by any person;
and the Company is unaware of any facts or circumstances which might give rise to any of the foregoing. The Company and each of
its subsidiaries have taken reasonable security measures to protect the secrecy, confidentiality and value of their Intellectual
Property.

 

3.10         No
Materially Adverse Contracts, Etc. Neither the Company nor any of its subsidiaries is subject to any charter, corporate or
other legal restriction, or any judgment, decree, order, rule or regulation which in the judgment of the Company’s officers
has or is expected in the future to have a Material Adverse Effect. Neither the Company nor any of its subsidiaries is a party
to any contract or agreement which in the judgment of the Company’s officers has or is expected to have a Material Adverse
Effect. No prior approval is required by the Company from any third party, including but not limited to any lender, to enter into
the Offering Documents and perform its respective obligations thereunder.

 

3.11         Tax
Status. The Company and each of its subsidiaries has made or filed all federal, state and foreign income and all other tax
returns, reports and declarations required by any jurisdiction to which it is subject (unless and only to the extent that the Company
and each of its subsidiaries has set aside on its books provisions reasonably adequate for the payment of all unpaid and unreported
taxes) and has paid all taxes and other governmental assessments and charges that are material in amount, shown or determined to
be due on such returns, reports and declarations, except those being contested in good faith and has set aside on its books provisions
reasonably adequate for the payment of all taxes for periods subsequent to the periods to which such returns, reports or declarations
apply. There are no unpaid taxes in any material amount claimed to be due by the taxing authority of any jurisdiction, and the
officers of the Company know of no basis for any such claim. The Company has not executed a waiver with respect to the statute
of limitations relating to the assessment or collection of any foreign, federal, state or local tax. None of the Company’s
tax returns is presently being audited by any taxing authority.

 

3.12         Certain
Transactions. Except for arm’s length transactions pursuant to which the Company or any of its subsidiaries makes payments
in the ordinary course of business upon terms no less favorable than the Company or any of its subsidiaries could obtain from third
parties and other than the grant of stock options disclosed in the SEC Documents, none of the officers, directors, or employees
of the Company is presently a party to any transaction with the Company or any of its subsidiaries (other than for services as
employees, officers and directors), including any contract, agreement or other arrangement providing for the furnishing of services
to or by, providing for rental of real or personal property to or from, or otherwise requiring payments to or from any officer,
director or such employee or, to the knowledge of the Company, any corporation, partnership, trust or other entity in which any
officer, director, or any such employee has a substantial interest or is an officer, director, trustee or partner.

 

    	8

    	 

    

 

3.13         Disclosure.
All information relating to or concerning the Company or any of its subsidiaries set forth in this Agreement and provided to the
Subscriber pursuant to Section 2.3 hereof and otherwise in connection with the transactions contemplated hereby is true and correct
in all material respects and the Company has not omitted to state any material fact necessary in order to make the statements made
herein or therein, in light of the circumstances under which they were made, not misleading. No event or circumstance has occurred
or exists with respect to the Company or any of its subsidiaries or its or their business, properties, prospects, operations or
financial conditions, which, under applicable law, rule or regulation, requires public disclosure or announcement by the Company
but which has not been so publicly announced or disclosed (assuming for this purpose that the Company’s reports filed under
the 1934 Act are being incorporated into an effective registration statement filed by the Company under the Securities Act).

 

3.14         Permits;
Compliance. The Company and each of its subsidiaries is in possession of all franchises, grants, authorizations, licenses,
permits, easements, variances, exemptions, consents, certificates, approvals and orders necessary to own, lease and operate its
properties and to carry on its business as it is now being conducted (collectively, the “Company Permits”),
and there is no action pending or, to the knowledge of the Company, threatened regarding suspension or cancellation of any of the
Company Permits. Neither the Company nor any of its subsidiaries is in conflict with, or in default or violation of, any of the
Company Permits, except for any such conflicts, defaults or violations which, individually or in the aggregate, would not reasonably
be expected to have a Material Adverse Effect. Since September 30, 2014, neither the Company nor any of its subsidiaries has received
any notification with respect to possible conflicts, defaults or violations of applicable laws, except for notices relating to
possible conflicts, defaults or violations, which conflicts, defaults or violations would not have a Material Adverse Effect.

 

3.15        Environmental
Matters.

 

 3.15.1         There
are, to the Company’s knowledge, with respect to the Company or any of its subsidiaries or any predecessor of the Company,
no past or present violations of Environmental Laws (as defined below), releases of any material into the environment, actions,
activities, circumstances, conditions, events, incidents, or contractual obligations which may give rise to any common law environmental
liability or any liability under the Comprehensive Environmental Response, Compensation and Liability Act of 1980 or similar federal,
state, local or foreign laws and neither the Company nor any of its subsidiaries has received any notice with respect to any of
the foregoing, nor is any action pending or, to the Company’s knowledge, threatened in connection with any of the foregoing.
The term “Environmental Laws” means all federal, state, local or foreign laws relating to pollution or protection
of human health or the environment (including, without limitation, ambient air, surface water, groundwater, land surface or subsurface
strata), including, without limitation, laws relating to emissions, discharges, releases or threatened releases of chemicals, pollutants
contaminants, or toxic or hazardous substances or wastes (collectively, “Hazardous Materials”) into the environment,
or otherwise relating to the manufacture, processing, distribution, use, treatment, storage, disposal, transport or handling of
Hazardous Materials, as well as all authorizations, codes, decrees, demands or demand letters, injunctions, judgments, licenses,
notices or notice letters, orders, permits, plans or regulations issued, entered, promulgated or approved thereunder.

 

    	9

    	 

    

 

 3.15.2         Other
than those that are or were stored, used or disposed of in compliance with applicable law, no Hazardous Materials are contained
on or about any real property currently owned, leased or used by the Company or any of its subsidiaries, and no Hazardous Materials
were released on or about any real property previously owned, leased or used by the Company or any of its subsidiaries during the
period the property was owned, leased or used by the Company or any of its Subsidiaries, except in the normal course of the Company’s
or any of its subsidiaries’ business.

 

3.16         Internal
Accounting Controls. The Company and each of its subsidiaries maintain a system of internal accounting controls sufficient,
in the judgment of the Company’s board of directors, to provide reasonable assurance that (i) transactions are executed in
accordance with management’s general or specific authorizations, (ii) transactions are recorded as necessary to permit preparation
of financial statements in conformity with generally accepted accounting principles and to maintain asset accountability, (iii)
access to assets is permitted only in accordance with management’s general or specific authorization and (iv) the recorded
accountability for assets is compared with the existing assets at reasonable intervals and appropriate action is taken with respect
to any differences.

 

3.17         Foreign
Corrupt Practices. Neither the Company, nor any of its subsidiaries, nor any director, officer, agent, employee or other person
acting on behalf of the Company or any subsidiary has, in the course of his actions for, or on behalf of, the Company, used any
corporate funds for any unlawful contribution, gift, entertainment or other unlawful expenses relating to political activity; made
any direct or indirect unlawful payment to any foreign or domestic government official or employee from corporate funds; violated
or is in violation of any provision of the U.S. Foreign Corrupt Practices Act of 1977, as amended, or made any bribe, rebate, payoff,
influence payment, kickback or other unlawful payment to any foreign or domestic government official or employee.

 

3.18         Solvency.
The Company (after giving effect to the transactions contemplated by this Agreement) is solvent (i.e., its assets have a
fair market value in excess of the amount required to pay its probable liabilities on its existing debts as they become absolute
and matured) and currently the Company has no information that would lead it to reasonably conclude that the Company would not,
after giving effect to the transaction contemplated by this Agreement, have the ability to, nor does it intend to take any action
that would impair its ability to, pay its debts from time to time incurred in connection therewith as such debts mature. The Company
did not receive a qualified opinion from its auditors with respect to its most recent fiscal year end and, after giving effect
to the transactions contemplated by this Agreement, does not anticipate or know of any basis upon which its auditors might issue
a qualified opinion in respect of its current fiscal year.

 

3.19         Breach
of Representations and Warranties by the Company. If the Company breaches any of the representations or warranties set forth
in this Section 3, and in addition to any other remedies available to the Subscriber pursuant to this Agreement, it will be considered
an Event of Default under Section 3 of the Note.

 

    	10

    	 

    

 

4.           Covenants.

 

4.1           Form
D; Blue Sky Laws. If required, the Company agrees to file a Form D with respect to the Securities as required under Regulation
D and to provide a copy thereof to the Subscriber promptly after such filing. The Company shall, on or before the sale of the Securities,
take such action as the Company shall reasonably determine is necessary to qualify the Securities for sale to the Subscriber at
the applicable closing pursuant to this Agreement under applicable securities or “blue sky” laws of the states of the
United States (or to obtain an exemption from such qualification), and shall provide evidence of any such action so taken to the
Subscriber on or prior to the closing date.

 

4.2           Listing.
The Company shall promptly secure the listing of the Conversion Shares upon The Nasdaq Stock Market and, so long as the Subscriber
owns any of the Securities, shall maintain such listing of all Conversion Shares from time to time issuable upon conversion of
the Note and/or the exercise of the Warrant. So long as the Subscriber owns any of the Securities, including the Conversion Shares,
the Company shall maintain the listing of its Common Stock on The Nasdaq Stock Market and will comply in all respects with the
Company’s reporting, filing and other obligations under the bylaws or rules thereof.

 

4.3           Corporate
Existence. So long as the Subscriber beneficially owns the Note, the Warrant or the Conversion Shares, the Company shall maintain
its corporate existence and shall not sell all or substantially all of the Company’s assets, except in the event of a merger
or consolidation or sale of all or substantially all of the Company’s assets, where the surviving or successor entity in
such transaction (i) assumes the Company’s obligations hereunder and under the agreements and instruments entered into in
connection herewith and (ii) is a publicly traded corporation whose common stock is listed for trading on a recognized securities
exchange.

 

4.4           No
Integration. The Company shall not make any offers or sales of any security (other than the Securities) under circumstances
that would require registration of the Securities being offered or sold hereunder under the Securities Act or cause the Offering
of the Securities to be integrated with any other offering of securities by the Company for the purpose of any stockholder approval
provision applicable to the Company or its securities.

 

4.5           Breach
of Covenants. If the Company breaches any of the covenants set forth in this Section 4, and in addition to any other remedies
available to the Subscriber pursuant to this Agreement, it will be considered an event of default under Section 3 of the Note.

 

4.6           Failure
to Comply with the 1934 Act. So long as the Subscriber beneficially owns the Note, the Warrant or the Conversion Shares, the
Company shall timely comply with the reporting requirements of the 1934 Act; and the Company shall continue to be subject to the
reporting requirements of the 1934 Act.

 

    	11

    	 

    

 

4.7           Subscriber
No-Short Covenant. In consideration of the agreement by the Company to offer and sell the Securities, and of other good
and valuable consideration the receipt and sufficiency of which is hereby acknowledged, the Subscriber agrees that it will not
offer, sell, contract to sell, pledge, grant any option to purchase, make any short sale or otherwise dispose of any Securities,
or any options or warrants to purchase any Securities, or any securities convertible into, exchangeable for or that represent the
right to receive any Securities, whether now owned or hereinafter acquired, owned directly by the Subscriber (including holding
as a custodian) or with respect to which the Subscriber has beneficial ownership, as such term is used in Rule 13d-3 of the 1934
Act. The foregoing restriction is expressly agreed to preclude the Subscriber from engaging in any hedging or other transaction
which is designed to or which reasonably could be expected to lead to or result in a sale or disposition of the Securities even
if such Securities would be disposed of by someone other than the Subscriber. Such prohibited hedging or other transactions would
include without limitation any short sale or any purchase, sale or grant of any right (including without limitation any put or
call option) with respect to any of the Securities or with respect to any security that includes, relates to, or derives any significant
part of its value from the Securities.

 

Section
5.             Miscellaneous.

 

5.1          Any
notice or other communication required, permitted or provided for hereunder (each, a “Notice”) shall be effective
as between the parties only if given in writing and sent by (a) personal delivery, (b) registered or certified mail (return receipt
requested); or (c) express delivery service, to the Company at 7621 Little Avenue, Suite 414, Charlotte, NC 28226, and to the Subscriber
at the address set forth on the Signature Page to this Agreement. Notice shall be deemed to have been duly given and received (i)
if personally delivered, on the date of such delivery, (ii) if mailed, on the date set forth on the return receipt, or (iii) if
delivered by express delivery, on the date of such delivery (as evidenced by the receipt provided to the express delivery service).
If Notice cannot be delivered because of a changed address of which no Notice was given, or the refusal to accept delivery, the
Notice shall be deemed received on the date it is sent (as evidenced by the affidavit of the sender).

 

5.2          Secretary’s
Certificate.  The Company shall deliver to the Subscriber, a secretary’s certificate, dated as of the each Closing
Date, as to (i) the resolutions adopted by the Board of Directors approving the transactions contemplated hereby, (ii) the Company’s
Articles of Incorporation, (iii) the Bylaws, each as in effect at such Closing, and (iv) the authority and incumbency of the officers
of the Company executing the Transaction Documents and any other documents required to be executed or delivered in connection therewith

 

5.3          Officer’s
Certificate. On each Closing Date, the Company shall have delivered to the Subscriber a certificate signed by an executive
officer on behalf of the Company, dated as of such first Closing Date, confirming the accuracy of the Company’s representations,
warranties, and covenants as of such Closing Date, setting forth the amount of fees and total interest it believes are included
as part of the issuance of the Notes and that, based on the foregoing the Company does not have reason to believe that the Notes
and Warrants are unenforceable for any reason.

 

5.4          This
Subscription Agreement shall be binding upon and inure to the benefit of the parties hereto and to their respective heirs, legal
representatives, successors and assigns. The Offering Documents set forth the entire agreements and understandings between the
parties as to the subject matter hereof and merges and supersedes all prior discussions, agreements and understandings of any and
every nature among them.

 

    	12

    	 

    

 

5.5           NOTWITHSTANDING
THE PLACE WHERE THIS SUBSCRIPTION AGREEMENT MAY BE EXECUTED BY ANY OF THE PARTIES HERETO, THE COMPANY AND SUBSCRIBER HEREBY: (A)
AGREE THAT ALL QUESTIONS CONCERNING THE CONSTRUCTION, VALIDITY, ENFORCEMENT AND INTERPRETATION OF THIS SUBSCRIPTION AGREEMENT SHALL
BE GOVERNED BY AND CONSTRUED AND ENFORCED IN ACCORDANCE WITH THE INTERNAL LAWS OF THE STATE OF NEW YORK WITHOUT REGARD TO THE PRINCIPLES
OF CONFLICTS OF LAW THEREOF, AND (B) ALL LEGAL PROCEEDINGS CONCERNING THE INTERPRETATION, ENFORCEMENT AND DEFENSE OF THIS SUBSCRIPTION
AGREEMENT SHALL BE COMMENCED IN THE STATE OR FEDERAL COURTS OF State of New York, County
of New York (THE “COURTS”), (C) IRREVOCABLY SUBMIT TO THE EXCLUSIVE JURISDICTION OF THE COURTS FOR THE ADJUDICATION
OF ANY DISPUTE HEREUNDER (INCLUDING WITH RESPECT TO THE ENFORCEMENT OF THIS SUBSCRIPTION AGREEMENT); (D) IRREVOCABLY WAIVE AND
AGREE NOT TO ASSERT IN ANY SUIT, ACTION OR PROCEEDING, ANY CLAIM THAT IT IS NOT PERSONALLY SUBJECT TO THE JURISDICTION OF ANY OF
SUCH COURTS, OR THAT SUCH SUIT, ACTION OR PROCEEDING IS IMPROPER; (E) IRREVOCABLY WAIVE PERSONAL SERVICE OF PROCESS AND CONSENTS
TO PROCESS BEING SERVED IN ANY SUCH SUIT, ACTION OR PROCEEDING BY MAILING A COPY THEREOF VIA REGISTERED OR CERTIFIED MAIL OR OVERNIGHT
DELIVERY (WITH EVIDENCE OF DELIVERY) TO THE OTHER AT THE ADDRESS IN EFFECT FOR NOTICES TO IT UNDER THIS SUBSCRIPTION AGREEMENT
AND AGREES THAT SUCH SERVICE SHALL CONSTITUTE GOOD AND SUFFICIENT SERVICE OF PROCESS AND NOTICE THEREOF (NOTHING CONTAINED HEREIN
SHALL BE DEEMED TO LIMIT IN ANY WAY ANY RIGHT TO SERVE PROCESS IN ANY MANNER PERMITTED BY LAW); AND (F) IRREVOCABLY WAIVE, TO THE
FULLEST EXTENT PERMITTED BY APPLICABLE LAW, ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY LEGAL PROCEEDING ARISING OUT OF OR RELATING
TO THIS SUBSCRIPTION AGREEMENT OR THE TRANSACTIONS CONTEMPLATED HEREBY.

 

5.6           This
Subscription Agreement may be executed in counterparts. Upon the execution and delivery of this Subscription Agreement by the Subscriber,
this Subscription Agreement shall become a binding obligation of the Subscriber with respect to the purchase of Securities as herein
provided; subject, however, to the right hereby reserved to the Company to enter into the same agreements with other subscribers
and to add and/or to delete other persons as subscribers.

 

5.7           If
any provision of this Subscription Agreement is declared by a court of competent jurisdiction to be in any way invalid, illegal
or unenforceable, the balance of this Subscription Agreement shall remain in effect, and if any provision is inapplicable to any
person or circumstance, it shall nevertheless remain applicable to all other persons and circumstances.

 

    	13

    	 

    

 

5.8           No
term or provision contained herein may be modified, amended or waived except by written agreement or consent signed by the party
or parties to be bound thereby. It is agreed that a waiver by either party of a breach of any provision of this Subscription Agreement
shall not operate, or be construed, as a waiver of any subsequent breach by that same party.

 

5.9           The
parties agree to execute and deliver all such further documents, agreements and instruments and take such other and further action
as may be necessary or appropriate to carry out the purposes and intent of this Subscription Agreement.

 

5.10         Subscriber
acknowledges that the subscription made hereby is not binding upon the Company until the Company accepts it. The Company has the
right to accept or reject this subscription in whole or in part in its sole and absolute discretion. If this subscription is rejected
in whole, the Company shall return the Purchase Price to Subscriber, without interest, and the Company and Subscriber shall have
no further obligation to each other by reason of this Subscription Agreement or the subscription made hereby. In the event of a
partial rejection of this subscription, a proportionate amount of the Purchase Price will be returned to Subscriber, without interest.

 

5.11         Legal
Fees. The Company shall reimburse legal fees to all Subscriber’s counsel, Ron Levy, Esq., in an amount not to
exceed $5,000 in the aggregate.

 

[Remainder of Page Intentionally Blank,
Signature Page Follows]

 

    	14

    	 

    

 

ATTACHMENT
A: USE OF PROCEEDS

 

	Corporate working capital	 	$	750,000	 

 

    	15

    	 

    

 

SIGNATURE
PAGE FOR INDIVIDUAL INVESTOR

 

IN WITNESS WHEREOF,
this Subscription Agreement has been executed by Subscriber and by the Company on the respective dates set forth below.

 

	    	   	 	    	        
	Signature	 	 	Signature (If Securities Purchased Jointly)

 

	Name	 	 	Name	 
	 	Please Print	 	 	Please Print

 

	Address	 	 	Address	 
	 	 	 	 	 

 

	Telephone #	 	 	Telephone #	 

 

	Fax #	 	 	Fax #	 

 

	Email:	 	 	Email:	 

 

	Social Security #	 	 	Social Security #	 

 

	Date:	 	 	Date:	 

 

Number of Units (each Unit consisting of
8% convertible note with principal amount of $50,000 and 12,500 shares of common stock warrants) Subscribed For: _______________________

 

Purchase Price: $  _______________________

 

Form of joint ownership of Securities
(if applicable):              ̈   JTTEN              ̈   JTWROS              ̈   JTTIC

 

	Exact Name in Which Securities are to be Registered: 	 

 

Subscription Accepted:

 

CHANTICLEER HOLDINGS, INC.

 

	By:	 	 	 
	 	Name:	 Michael D. Pruitt	 
	 	Title:	President/CEO	 

 

	Date:	 	 

 

THE COMPANY
RESERVES THE RIGHT TO REFUSE TO ACCEPT ANY

 SUBSCRIPTION, IN WHOLE OR IN PART, FOR ANY REASON WHATSOEVER.

    	16

    	 

    

 

SIGNATURE
PAGE FOR PARTNERSHIP, CORPORATION,

LIMITED LIABILITY COMPANY, TRUST, OR OTHER ENTITY

 

IN WITNESS WHEREOF,
the undersigned has executed this Subscription Agreement on the date set forth below.

 

	 	 
	Name of partnership, corporation, limited liability	 
	company or trust	 

 

	By:	 	 	Federal Tax ID Number	 

 

	Name:	 	 

 

	Title:	 	 	State of Organization	 

 

	Address:	 	 
	 	 	 

 

	Telephone:	 	 

 

	Fax:	 	 

 

	Email:	 	 

 

	Date:	 	 

 

Number of Units (each Unit consisting of
8% convertible note with principal amount of $50,000 and 12,500 shares of common stock warrants) Subscribed For:  _______________________

 

Purchase Price: $ _______________________

 

	Exact Name in Which Securities are to be Registered: 	 

 

Subscription Accepted:

 

CHANTICLEER HOLDINGS, INC.

 

	By:	 	 	 
	 	Name:	 Michael D. Pruitt	 
	 	Title:	President / CEO	 

 

	Date:	 	 

 

THE COMPANY
RESERVES THE RIGHT TO REFUSE TO ACCEPT ANY 

SUBSCRIPTION, IN WHOLE OR IN PART, FOR ANY REASON WHATSOEVER.

 

    	17

    	 

    

 

SPECIAL SUBSCRIPTION INSTRUCTIONS FOR
CORPORATE, PARTNERSHIP, 

LIMITED LIABILITY COMPANY, TRUST, OTHER ENTITY, AND JOINT 

PURCHASERS

 

If Subscriber is a
corporation, partnership, limited liability company, trust, or other entity or joint purchaser, the following additional instructions
must be followed. INFORMATION ADDITIONAL TO THAT REQUESTED BELOW MAY ALSO BE REQUIRED BY THE COMPANY IN SOME CASES.

 

1.          Certificate.
Subscriber must date and sign the Certificate below, and, if requested by the Company, Subscriber may also be required to provide
a copy of (a) the corporation’s articles of incorporation, bylaws and authorizing resolution, (b) the partnership agreement,
(c) the limited liability company’s certificate of formation or articles of organization, as applicable, and limited liability
company agreement, operating agreement or similar agreement governing the rights and obligations of the members of the limited
liability company, or (d) the trust agreement or other governing documents, as applicable.

 

2.          Subscription
Agreement.

 

(a)          Corporations.
An authorized officer of the corporation must date, sign, and complete the Subscription Agreement with information concerning the
corporation. The officer should print the name of the corporation above his signature, and print his name and office below his
signature.

 

(b)          Partnerships.
An authorized partner must date, sign, and complete the Subscription Agreement with information concerning the partnership. The
partner should print the name of the partnership above his signature, and print his name and the words “general partner”
below his signature.

 

(c)          Limited
Liability Companies. An authorized member or manager must date, sign, and complete the Subscription Agreement with information
concerning the limited liability company. The member or manager should print the name of the limited liability company above his
signature, and print his name and the word “member” or “manager” below his signature.

 

(d)          Trusts.
In the case of a trust, the authorized trustee should date, sign, and complete the Subscription Agreement with information concerning
the trust. The trustee should print the name of the trust above his signature, and print his name and the word “trustee”
below his signature. In addition, an authorized trustee should also provide information requested in the Subscription Agreement
as it pertains to him as an individual.

 

(e)          Joint
Ownership. In all cases, each individual must date, sign, and complete the Subscription Agreement. Joint investors must state
if they are purchasing the Securities as joint tenants with the right of survivorship, tenants in common, or community property,
and each must execute the Subscription Agreement signature page.

 

    	18

    	 

    

 

CERTIFICATE FOR CORPORATE, PARTNERSHIP,

LIMITED LIABILITY COMPANY, TRUST, OR
OTHER ENTITY

 

If Subscriber is a
corporation, partnership, limited liability company, trust, or other entity, an authorized officer, partner, member, manager or
trustee must complete, date and sign this Certificate.

 

CERTIFICATE

 

I hereby certify that:

 

1.           Subscriber
has been duly formed, is validly existing and in good standing, and has full power and authority to purchase the Securities and
make an investment in Chanticleer Holdings, Inc.

 

2.           The
Subscription Agreement has been duly and validly authorized, executed, and delivered by Subscriber and constitutes the valid, binding,
and enforceable obligation of Subscriber.

 

	Date:	 	 	 
	 	 	 	Name of corporation, partnership, limited liability company, trust or other entity
	 	 	 	(please print)
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	Signature and title of authorized officer, partner, member, manager, trustee, or other entity

 

    	19

    	 

    

 

ACCREDITED INVESTOR QUESTIONNAIRE

 

_______________________

 

**ALL INFORMATION WILL BE HELD IN STRICTEST
CONFIDENCE**

 

INSTRUCTIONS TO THE PROSPECTIVE INVESTOR:
This Questionnaire is being sent to each prospective investor that has indicated an interest in purchasing Securities of Chanticleer
Holdings, Inc. (the “Company”). The purpose of this Questionnaire is to assure the Company that each prospective
subscriber to its Securities (“Subscriber”) will meet the standards imposed by Regulation D, promulgated under
the Securities Act of 1933, and similar exemptions provided by the applicable state securities laws and regulations promulgated
there under (the “Securities Laws”). Since the Securities will not be registered, each subscriber must complete
the following Questionnaire.

 

The information provided will be used to
determine whether the prospective purchaser’s Subscription Agreement to purchase Securities will be accepted by the Company
in light of the requirements of Securities Laws. In subscribing for Securities and furnishing the information requested in this
Questionnaire, the Subscriber understands that the Company will rely on the information provided herein for purposes of such determinations.
The Subscriber understands that a false representation may constitute a violation of law and that any person who suffers damage
as a result of a false representation may have a claim against the Subscriber for damages.

 

The information provided herein by Subscribers
will be kept confidential. However, by signing this Questionnaire, the Subscriber agrees that the Company may present the completed
document to such parties as it deems appropriate if called upon to establish the availability under any Securities Laws.

 

In accordance with the foregoing, the following
representations are hereby made and the following information is furnished by the undersigned subscriber.

 

PART A. GENERAL INFORMATION

 

	NAME(S) OF PROSPECTIVE SUBSCRIBER(S):	 
	 	 
	 	 

 

	Social Security Number or Tax I.D. No.:	 

 

    	20

    	 

    

PART B. INVESTOR INFORMATION

 

1.          Please
review this checklist and check each box that is applicable:

 

YOU MUST BE ABLE TO CHECK OFF AT LEAST
ONE OF THE BOXES BELOW IN ORDER TO PURCHASE SECURITIES.

 

	 ̈	The undersigned is a natural person who had individual income of more than $200,000 in each of the most recent two years or joint income with his or her spouse in excess of $300,000 in each of the most recent two years and reasonably expects to reach that same income level for this year; “income”, for purposes hereof, should be computed as follows:  individual adjusted gross income, as reported (or to be reported) on a federal income tax return, increased by (a) any deduction of long-term capital gains under section 1202 of the Internal Revenue Code of 1986 (the “Code”), (b) any deduction for depletion under Section 611 et seq. of the Code, (c) any exclusion for interest under Section 103 of the Code and (d) any losses of a partnership as reported on Schedule E of Form 1040;
	 ̈	The undersigned is a natural person whose individual net worth (i.e., total assets in excess of total liabilities), or joint net worth with his or her spouse, excluding the undersigned’s primary residence, will at the time of purchase of the Securities be in excess of $1,000,000;
	 ̈	The undersigned is a corporation, Massachusetts or similar business trust, partnership, or limited liability company, or an organization described in Section 501(c)(3) of the Internal Revenue Code, not formed for the specific purpose of acquiring the Securities, with total assets in excess of $5,000,000;
	 ̈	The undersigned is a trust (other than a revocable grantor trust), which trust has total assets in excess of $5,000,000, which is not formed for the specific purpose of acquiring the Securities offered hereby and whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D and who has such knowledge and experience in financial and business matters that he or she is capable of evaluating the risks and merits of an investment in the Common Securities;
	 ̈	The undersigned is an employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974, and either: (a) the investment decision will be made by a plan fiduciary, as defined in Section 3(21) of such act, which is either a bank, insurance company, or a registered investment adviser; or (b) the employee benefit plan has total assets in excess of $5,000,000; or (c) the employee benefit plan is a self-directed plan, including an Individual Retirement Account, within the meaning of Title I of such act, and the person directing the purchase is an Accredited Investor**;
	 	**NOTE:  If the undersigned is relying solely on this item for its Accredited Investor status, please print the name of the person directing the purchase in the following space and furnish a completed and signed Accredited Investor Certification for such person.
	 ̈	The undersigned is an investor otherwise satisfying the requirements of Section 501(a)(1), (2) or (3) of Regulation D promulgated under the 1933 Act, which includes, but is not limited to, a self-directed employee benefit plan where investment decisions are made solely by persons who are “accredited investors” as otherwise defined in Regulation D;
	 ̈	The undersigned is a member of the Board of Directors or an executive officer of the Company; or
	 ̈	The undersigned is an entity (including an IRA or revocable grantor trust but other than a conventional trust) in which all of the equity owners meet the requirements of at least one of the above subparagraphs.

 

    	21

    	 

    

 

		2.	(a)      Do you, or in the case of an entity, management,
by reason of prior business or financial expense, have the capacity to protect yours or its own interest in connection with an
investment in the Securities?

 

Yes _______
    No _______

 

(b)     Do you
have substantial experience in evaluating and investing in private placement transactions of securities in entities similar to
the Company so that you are capable of evaluating the merits and risks of an investment in the Securities?

 

Yes _______

    No _______

 

		3.	Have you purchased the Securities for investment purposes
and not with a view toward resale or distribution, and will, prior to any sale or attempted sale of any of the Securities, comply
with all requirements of the state and federal securities acts?

 

Yes _______

    No _______

 

		4.	Do you understand that Securities cannot be readily sold
because there will be no public market for them, that the Securities are not suitable for any investor unless that investor has
available personal liquid assets to provide for financial contingencies and that a condition to any sale would be the registration
of such interests or the availability of an exception to such registration requirements?

 

Yes _______

    No _______

 

		5.	Is your principal investment objective to secure an economic
profit, determined without regard to any tax benefits which you may receive?

 

Yes _______

    No _______

 

		6.	Do you understand that the Securities encompass substantial
risks?

 

Yes _______

    No _______

 

		7.	Do you acknowledge that no independent due diligence
has been undertaken except for that performed by yourself and your purchaser representative, if applicable?

 

Yes _______

    No _______

 

		8.	Do you understand that no attorney-client relationship
has arisen in connection with this offering between any prospective Subscriber and counsel to the Company or between any prospective
Subscriber and counsel to any other investor?

 

Yes _______

    No _______

 

		9.	(a)     Do you plan to use a “Purchaser Representative”
to assist you in analyzing this investment?

 

Yes _______

    No _______

 

If “Yes”,
please provide Purchaser Representative’s name and address:

 

    	22

    	 

    

 

 

 

 

 

(b)      If “No”,
do you have such knowledge and experience in financial andbusiness matters that you are capable of evaluating the merits and
risks of this investment?

 

Yes _______
No _______

 

I REPRESENT THAT THE ABOVE
INFORMATION IS CORRECT. I HEREBY AUTHORIZE THE COMPANY TO VERIFY SUCH INFORMATION WITH MY ATTORNEY, BANKER, ACCOUNTANT OR OTHER
ADVISORS(S).

 

	Date:	 	 	 
	 	 	 	Subscriber’s Signature
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	Subscriber’s Signature

 

    	23

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