Document:

Exhibit 10.1

 

QS ENERGY, INC.

TERM SHEET

NOTE PURCHASE AGREEMENT

October 15, 2021

 

	OFFERING	 

 

	INVESTMENT	Minimum Aggregate Investment of $25,000;

                                            Maximum Aggregate Investment of $200,000;

                                            Minimum Individual Investment of $5,000.

 

	SECURITY	Convertible Promissory Note.
	 	 
	MATURITY DATE	Twelve Months from date of
Closing.

 

	CONVERTIBILITY	Conversion price of $0.03 per share.

 

	PRINCIPAL	The principal amount of each Note will be 110% of the invested amount.

 

	INTEREST	Implied annual interest rate of 10%, inasmuch as the Note will be issued and paid in an amount equal to 110% of the invested amount.
If each Note is not paid in full on the Maturity Date, the unpaid balance will be increased by 10% and the new balance will bear interest
at 10% per annum.

 

	WARRANTS	The Warrants shall be issued at the same time each Note is issued to the Purchaser hereunder and shall
be exercisable at $0.04 per share (the “Exercise Price”), for such number of shares equal to 100% of the result obtained by
dividing (i) the face amount of the Notes issued simultaneously with the Warrant by (ii) the Conversion Price. The Warrants shall expire
one (1) year from the date of issuance thereof.
	 	 
	 	Example: A $50,000 investment will receive a Note at a principal amount of $55,000,
               convertible to 1,833,333 shares of common stock and a Warrant to purchase up to 1,833,333 shares at $0.04 per share.

 

	CLOSING	The Closing Date of this Offering is on or before November 30, 2021. This Offering will close before
November 30, 2021 if fully subscribed at the Maximum Aggregate Investment amount defined above.

 

	REPAYMENT	Each Note can be repaid without penalty on or before the Maturity Date. If each Note is not paid in
full on the Maturity Date, the unpaid balance will be increased by 10% and the new balance will bear interest at 10% per annum.

 

	ELIGIBILITY	Accredited investors. Principals only.

 

	RESTRICTIONS	 
	ON TRANSFER	The Notes, the Warrants and the shares of Common Stock issuable upon conversion of the Notes or exercise
                           of the Warrants are not and will not be registered with or approved by the Securities and Exchange Commission
                           (“SEC”) or any state securities agency, and when issued will be deemed restricted securities and
                           bear appropriate legends.

 

The above summary
provides selected limited information regarding this offering and should be read in conjunction with, and is qualified in its entirety
by, the Securities Purchase Agreement, Form of Convertible Promissory Note and Form of Stock Warrant. There are substantial risks associated
with, and you must be prepared to bear the entire loss of, an investment in our Convertible Promissory Notes. We have agreed to make available,
prior to the consummation of the transaction contemplated herein, to each purchaser of our Convertible Promissory Notes, or his or her
or its representative(s) or both, the opportunity to ask questions of, and receive answers from, us or any person acting on our behalf
concerning the terms and conditions of this offering, and to obtain any additional information, to the extent that we possess such information
or can acquire it without unreasonable effort or expense, necessary to verify the accuracy of information about us and this offering.
We are a SEC reporting company, and, as such, make periodic filings with the SEC, which filings are available at www.sec.gov.
We urge you to review our filings, as well as the Securities Purchase Agreement, Form of Convertible Note and Form of Stock Purchase Warrant,
before deciding whether or not to invest in our Convertible Promissory Notes. In particular, we refer you to the Risk Factors section,
Management Discussion section and audited financials of our Form 10-K for the fiscal year ended December 31, 2020, filed with the SEC
on July 22, 2021. Upon request, we will provide you with hard copies of the aforementioned SEC filing.

 

 

 

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SECURITIES PURCHASE AGREEMENT

Convertible Promissory Notes
and

Stock Purchase Warrants

 

THIS SECURITIES
PURCHASE AGREEMENT (this “Agreement”) is made and entered into as of _____________, 2021 by and between QS Energy, Inc., a
Nevada corporation (the “Issuer”) and those individuals and entities who sign and deliver an executed copy of this Agreement
to the Issuer (each, a “Purchaser” and collectively, the “Purchasers”), with reference to the following:

 

RECITALS

 

A.                 
Purchasers desire to purchase from Issuer and Issuer desires to sell to Purchaser certain of Issuer’s Convertible Notes,
in the aggregate face amount up to a maximum of Two Hundred Thousand Dollars ($200,000) in the form of Exhibit A attached hereto
(individually, a “Note” and collectively, the “Notes”), and certain of Issuer’s Stock Purchase Warrants
to purchase up to a certain number of shares of the common stock (the “Common Stock”) of the Issuer equal to 100% of the number
of shares initially issuable on conversion of the Notes, in the form of Exhibit B attached hereto (individually, the “Warrants”
and collectively with the Notes, the “Securities”). The face amount of the Note each Purchaser has committed to purchase,
and the amount of the purchase price thereof to be paid to the Issuer by the Purchaser (a “Commitment”) is listed on the signature
page such Purchaser executes and delivers to the Issuer. Minimum Commitment shall be no less than $5,000.

 

B.                 
Issuer’s sale of the Securities to the Purchasers may be made in reliance upon the provisions of Section 4(a)(2) under the
Securities Act of 1933, as amended (the "Securities Act") or Rule 506 of Regulation D promulgated by the Securities and Exchange
Commission (the ”SEC”) thereunder, or other applicable rules and regulations of the SEC or upon such other exemption from
the registration requirements of the Securities Act as may be available with respect to the transactions contemplated hereby.

 

C.                 
At any time when any amount of principal or interest of the Notes shall be outstanding, such unpaid amounts shall be convertible,
at the election of the Purchaser, into shares of the Issuer’s Common Stock at a price of $0.03 per share (the “Conversion
Price”).

 

D.                 
The Warrants shall be issued at the same time each Note is issued to the Purchaser hereunder and shall be exercisable at $0.04
per share (the “Exercise Price”), for such number of shares equal to 100% of the result obtained by dividing (i) 
the face amount of the Notes issued simultaneously with the Warrant by (ii) the Conversion Price. The Warrants shall expire one
(1) year from the date of issuance thereof.

 

AGREEMENT

 

NOW THEREFORE,
in consideration of the foregoing recitals, which shall be considered an integral part of this Agreement, the covenants and agreements
set forth hereafter, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Purchasers
and the Issuer hereby agree as follows

 

1.  
Purchase of the Notes and Warrants. On the terms and subject to the conditions set forth in this Agreement and in the Notes
and Warrants, the Purchasers shall purchase from the Issuer and the Issuer shall sell to the Purchaser the Securities.

 

 

 

    	 	2	 

     

    

 

2. 
Purchaser’s Representations, Warranties and Covenants. In order to induce the Issuer to sell and issue the Securities
to the Purchaser under one or more exemptions from registration under the Securities Act, the Purchasers, severally and not jointly, represent
and warrant to the Issuer, and covenant with the Issuer, that:

 

(a)         
(i)      Such Purchaser has the requisite power and authority to enter into and perform this Agreement, and each of the other agreements
entered into by the parties hereto in connection with the transactions contemplated by this Agreement (collectively, the "Transaction
Documents"), and to purchase the Securities in accordance with the terms hereof and thereof.

 

(ii)   
The execution and delivery of the Transaction Documents by the Purchaser and the consummation by it of the transactions contemplated
thereby have been duly and validly authorized by the Purchaser's organizational documents and no further consent or authorization is required
by the Purchaser.

 

(iii) 
  The Transaction Documents have been duly and validly executed and delivered by the Purchaser.

 

(iv)  
The Transaction Documents, and each of them, constitutes the valid and binding obligation of the Purchaser enforceable against
the Purchaser in accordance with their respective terms, except as such enforceability may be limited by general principles of equity
or applicable bankruptcy, insolvency, reorganization, moratorium, liquidation or similar laws relating to, or affecting generally, the
enforcement of creditors' rights and remedies.

 

(b)         
The execution, delivery and performance of the Transaction Documents by the Purchaser and the consummation by the Purchaser of
the transactions contemplated thereby will not conflict with or constitute a default under any agreement or instrument to which the Purchaser
is a party or by which the Purchaser is bound.

 

(c)         
The Purchaser is acquiring the Securities for investment for its own account, and not with a view toward distribution thereof,
and with no present intention of dividing its interest with others or reselling or otherwise transferring or disposing of all or any portion
of either the Notes or Warrants. The undersigned has not offered or sold a participation in this purchase of either the Notes or Warrants,
and will not offer or sell any interest therein. The Purchaser further acknowledges that the Purchaser does not have in mind any sale
of either the Notes or Warrants currently or after the passage of a fixed or determinable period of time or upon the occurrence or non-occurrence
of any predetermined events or consequence; and that it has no present or contemplated agreement, undertaking, arrangement, obligation,
indebtedness or commitment providing for or which is likely to compel a disposition of either the Notes or Warrants and is not aware of
any circumstances presently in existence that are likely in the future to prompt a disposition thereof.

 

(d)        
The Purchaser acknowledges that the Securities have been offered to it in direct communication between itself and the Issuer and
not through any advertisement, article, notice or other communication regarding the Securities published in any newspaper, magazine or
similar media or on the Internet or broadcast over television or radio or presented in any seminar or any other general solicitation or
general advertisement.

 

(e)         
The Purchaser acknowledges that the Issuer has given it access to all information relating to the Issuer’s business that
it has requested. The Purchaser has reviewed all materials relating to the Issuer's business, finance and operations which it has requested
and the Purchaser has reviewed all of such materials as the Purchaser, in the Purchaser’s sole and absolute discretion shall have
deemed necessary or desirable. The Purchaser has had an opportunity ask questions of and to discuss the business, management and financial
affairs of the Issuer with the Issuer's management. Specifically but not by way of limitation, the Purchaser acknowledges the Issuer’s
publicly available filings made periodically with the SEC, which filings are available at www.sec.gov
and which filings the Purchaser acknowledges reviewing or having had the opportunity of reviewing.

 

 

 

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(f)          The Purchaser
acknowledges that it has, by reason of its business and financial experience, knowledge, sophistication and experience in financial and
business matters and in making investment decisions of this type that it is capable of (i) evaluating the merits and risks of an investment
in the Securities and making an informed investment decision in connection therewith; (ii) protecting its own interest; and (iii) bearing
the economic risk of such investment for an indefinite period of time for Securities which are not transferable or freely tradable. The
undersigned hereby agrees to indemnify the Issuer thereof and to hold each of such persons and entities, and the officers, directors and
employees thereof harmless against all liability, costs or expenses (including reasonable attorneys’ fees) arising by reason of
or in connection with any misrepresentation or any breach of warranties of the undersigned contained in this Agreement, or arising as
a result of the sale or distribution of the Securities or the Common Stock issuable upon conversion of the Notes or exercise of the Warrants,
by the undersigned in violation of the Securities Act, the Securities Exchange Act of 1934, as amended (the “Exchange Act”),
or any other applicable law, either federal or state. This subscription and the representations and warranties contained herein shall
be binding upon the heirs, legal representatives, successors and assigns of the Purchaser.

 

(g)       
The Purchaser is familiar with the definition of an "accredited investor" as that term is defined in Rule 501(a) of
Regulation D of the Securities Act and represents and warrants to the Issuer that it is either (i) an accredited investor at such time
it was offered the Securities and will be on each date which it converts any of the Notes or exercises any of the Warrants as so defined
or (ii) a “qualified institutional buyer” as defined in Rule 144A under the Securities Act. Such Purchaser is not required
to be registered as a broker-dealer under Section 15 of the Exchange act. If the Purchaser is not a resident of the United States, the
Purchaser is not a “U.S. person[s]” as that term is defined in Rule 902 of Regulation S promulgated under the Securities
Act of 1933, as amended.

 

(h)         
During the term of this Agreement and the other Transaction Documents, the Purchaser will comply with the provisions of Section
9 of the Exchange Act, and the rules and regulations promulgated thereunder, with respect to transactions involving the Common Stock.
Commencing on the date on which the Purchaser received a term sheet from the Company or any representative or agent of the Company (written
or oral) setting forth the material terms of the transactions contemplated hereunder until the date hereof and during the term of this
Agreement and the other Transaction Documents, the Purchaser agrees not to sell the Issuer's Common Stock short or engage in any hedging
transactions in the Issuer’s Common Stock, either directly or indirectly, through its affiliates, principals, agents or advisors.

 

(i)          
The Purchaser is aware that the Notes and the Warrants, and the shares of Common Stock issuable upon conversion of the Notes or
exercise of the Warrants are restricted securities as defined under federal securities laws and are not freely tradeable and may only
be disposed of in compliance with state and federal securities laws. In connection with any transfer of the Notes and the Warrants, and
the shares of Common Stock issuable upon conversion of the Notes or exercise of the Warrants, other than pursuant to an effective registration
statement or Rule 144, the Issuer may require the transferor thereof to provide to the Issuer an opinion of counsel, the form and substance
of which opinion shall be reasonably satisfactory to the Issuer, to the effect that such transfer does not require registration of such
transferred Securities under the Securities Act. Further, the Purchaser understands and acknowledges that any certificates evidencing
the Notes, the Warrants or the shares of Common Stock issuable upon conversion of the Notes or exercise of the Warrants will be restricted
securities and not freely tradeable and will bear the legend in substantially the following form:

 

THE SECURITIES EVIDENCED
BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR QUALIFIED FOR SALE UNDER ANY STATE SECURITIES
LAWS (COLLECTIVELY, “SECURITIES LAWS”) AND MAY NOT BE OFFERED, SOLD OR OTHERWISE TRANSFERRED UNLESS REGISTERED OR QUALIFIED
FOR SALE UNDER ALL APPLICABLE SECURITIES LAWS OR UNLESS, IN THE OPINION OF COUNSEL SATISFACTORY TO THE ISSUER, IN FORM AND SUBSTANCE SATISFACTORY
TO THE ISSUER, ANY SUCH OFFER, SALE OR OTHER TRANSFER IS EXEMPT FROM THE REGISTRATION OR QUALIFICATION REQUIREMENTS OF SUCH SECURITIES
LAWS.

 

(j)          The Purchaser
understands and acknowledges that following the purchase of the Notes, the Warrants and any shares of Common Stock issuable upon conversion
of the Notes or exercise of the Warrants, each may only be disposed of pursuant to either (i) an effective registration statement under
the Securities Act or (ii) an exemption from the registration requirements of the Securities Act.

 

 

 

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(k)         
The Purchaser understands and acknowledges that the Issuer has neither filed a registration statement with the SEC or any state
authorities nor agreed to do so, nor contemplates doing so in the future for the transactions contemplated by this Agreement or the other
Transaction Documents, and in the absence of such a registration statement or exemption, the undersigned may have to hold the Notes, the
Warrants and any shares of Common Stock issuable upon conversion of the Notes or exercise of the Warrants, indefinitely and may be unable
to liquidate any of them in case of an emergency.

 

(l)          
The Purchaser is purchasing the Notes and Warrants, and will acquire any shares of Common Stock issuable upon conversion of the
Notes or exercise of the Warrants, for its own account for investment purposes and not with a view towards distribution and agrees to
resell or otherwise dispose of any of the Notes or the Warrants, or any shares of Common Stock issuable upon conversion of the Notes or
exercise of the Warrants, in accordance with the registration provisions of the Securities Act (or pursuant to an exemption from such
registration provisions).

 

(m)        
The Purchaser is not and will not be required to be registered as a "dealer" under the Exchange Act, either as a result
of its execution and performance of its obligations under this Agreement or otherwise.

 

(n)         
The Purchaser understands and acknowledges that proceeds raised in connection with this Agreement will be used by Issuer for general
working capital purposes, including without limitation, the payment of salaries and professional fees, overhead and general administrative
expenses.

 

(o)         
The Purchaser understands that it is liable for its own tax liabilities and has obtained no tax advice from the Issuer in connection
with the purchase of the Securities.

 

(p)         
The Purchaser will not pay or receive any finder’s fee or commission in respect of the consummation of the transactions contemplated
by this Agreement.

 

(q)         
Purchaser hereby agrees and acknowledges that it has been informed of the following: (i) there are factors relating to the subsequent
transfer of any of the Securities or shares of Common Stock underlying the Notes and Warrants that could make the resale of such Securities
or shares of Common Stock underlying the Notes and Warrants difficult; and (ii) there is no guarantee that the Purchaser will realize
any gain from the purchase of the Securities. The purchase of the Securities involves a high degree of risk and is subject to many uncertainties.
These risks and uncertainties may adversely affect the Company’s business, operating results and financial condition. In such an
event, the trading price for the Common Stock could decline substantially and Purchaser could lose all or part of its investment. Purchaser
is urged to review the risks identified under the Risk Factors section of Issuer’s Form 10-K for the year ended December 31, 2020,
as filed with the SEC on July 22, 2021.

 

(r)         
Purchaser understands and acknowledges that the Notes have an implied annual interest rate of 10%, inasmuch as the Notes will be
issued and paid in an amount equal to 110% of the Commitment, except that if a Note is not paid on the Maturity Date, which is twelve
(12) months from the date of issue of the Note, then the balance of the unpaid amount of the Note shall be increased by 10% and the Issuer
shall then commence paying interest thereon at the rate of 10% per annum until all sums due under the Note are paid.

 

		3.	Issuer’s Representations, Warranties and Covenants. The Issuer represents and warrants to the Purchaser that:

 

(a)           
The Issuer is a corporation duly organized and validly existing in good standing under the laws of the State of Nevada, and has
the requisite corporate power and authorization to own its properties and to carry on its business as now being conducted.

 

 

 

    	 	5	 

     

    

 

(b)          
(i)      The Issuer has the requisite corporate power and authority to enter into and perform this Agreement, and each of the other
agreements entered into by the parties hereto in connection with the transactions contemplated by the Transaction Documents, and to issue
the Notes and Warrants in accordance with the terms hereof and thereof.

 

(ii)    
the execution and delivery of the Transaction Documents by the Issuer and the consummation by it of the transactions contemplated
hereby and thereby, including without limitation the reservation for issuance and the issuance of the Notes and Warrants pursuant to this
Agreement, have been duly and validly authorized by the Issuer's Board of Directors and no further consent or authorization is required
by the Issuer, its Board of Directors, or its shareholders.

 

 (iii)    The Transaction Documents have been duly and validly executed and delivered by the Issuer.

 

(iv)  
The Transaction Documents, and each of them, constitutes the valid and binding obligation of the Issuer enforceable against the
Issuer in accordance with their respective terms, except as such enforceability may be limited by general principles of equity or applicable
bankruptcy, insolvency, reorganization, moratorium, liquidation or similar laws relating to, or affecting generally, the enforcement of
creditors' rights and remedies.

 

(c)          
The execution, delivery and performance of the Transaction Documents by the Issuer and the consummation by the Issuer of the transactions
contemplated thereby will not conflict with or constitute a default under any agreement or instrument to which the Issuer is a party or
under any organizational documents of the Purchaser.

 

		4.	Closing and Deliverables.

 

(a)          
Subject to the provisions of Section 4(b) below, provided that the Issuer shall have received on or prior to November 30, 2021
copies of this Agreement executed by Purchaser, there shall be a closing or closings (each, a “Closing Date”) at which:

 

(i)     
Purchaser shall deliver to the Issuer immediately available funds, by check or by wire transfer (bank wiring instructions to be
provided by Issuer on request) in an amount equal to the amount of the Purchaser’s Commitment as set forth beside the name of the
Purchaser on the Purchaser’s signature page hereto. Funds paid to Issuer under this Agreement will be deposited in Issuer’s
operating account and used as working capital.

 

(ii)    
The Issuer shall deliver to the Purchaser (x) a Note, in the face amount equal to 110% of the Purchaser’s Commitment and
(y) a Warrant to purchase the exercisable amount of the Issuer’s Common Stock at the Exercise Price. The Note and Warrant will be
dated as of the Closing Date, as such date may be extended by us.

 

(b)          
The Issuer may continue to accept Commitments from Purchasers and issue and sell Securities to Purchasers at Closings on the terms
and subject to the conditions set forth in this Agreement until (i) the aggregate amount of the Commitments equals $200,000 or (ii) on
or before November 30, 2021, whichever shall first occur.

 

		5.	Miscellaneous.

 

(a)           Each party
shall pay the fees and expenses of its own advisers, counsel, accountants and other experts, if any, and all other expenses incurred by
such party incident to the negotiation, preparation, execution, delivery and performance of the Transactions Documents.

 

(b)          
This Agreement may be executed in two or more identical counterparts, all of which shall be considered one and the same agreement
and shall become effective when counterparts have been signed by each party and delivered to the other party; provided that a facsimile
signature or signature transmitted by e-mail shall be considered due execution and shall be binding upon the signatory thereto with the
same force and effect as if the signature were an original signature.

 

 

 

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(c)          
The headings of this Agreement are for convenience of reference and shall not form part of, or affect the interpretation of, this
Agreement. Whenever required by the context of this Agreement, the singular shall include the plural and neutral shall include the masculine
and feminine.

 

(d)          
If any provision of this Agreement shall be invalid or unenforceable in any jurisdiction, such invalidity or unenforceability shall
not affect the validity or enforceability of the remainder of this Agreement in that jurisdiction or the validity or enforceability of
any provision of this Agreement in any other jurisdiction.

 

(e)          
This Agreement and the Notes and Warrants represent the final agreement between the Purchasers and the Issuer with respect to the
terms and conditions set forth herein, and, the terms of this Agreement and the Notes and Warrants may not be contradicted by evidence
of prior, contemporaneous, or subsequent oral agreements of the parties. No provision of this Agreement and the Notes and Warrants may
be amended other than by an instrument in writing signed by the Purchaser and the Issuer, and no provision hereof or thereof may be waived
other than by an instrument in writing signed by the party against whom enforcement is sought.

 

(f)           
Any notices or other communications required or permitted to be given under the terms of this Agreement must be in writing and
will be deemed to have been delivered (i) upon receipt, when delivered personally; (ii) upon receipt, when sent by facsimile (provided
confirmation of transmission is mechanically or electronically generated and kept on file by the sending party); or (iii) one (1) day
after deposit with a nationally recognized overnight delivery service, in each case properly addressed to the party to receive the same.
The addresses and facsimile numbers for such communications shall be:

 

If to the Issuer:

 

QS Energy, Inc.

3606 Challenger Way, Unit #1

Carson City, NV 89706

Telephone: (775) 300-7647

Fax: (775) 300-7593

 

If to a Purchaser:

 

To the address set forth on the Purchaser’s signature
page hereto.

 

Each party shall provide five (5) days prior written notice
to the other party of any change in address or facsimile number.

 

 (g)           This Agreement may not be assigned by Purchaser.

 

(h)          
This Agreement is intended for the benefit of the parties hereto and is not for the benefit of, nor may any provision hereof be
enforced by, any other person.

 

(i)           
The representations and warranties of the Purchaser and the Issuer contained herein shall survive each of the Closings and the
termination of this Agreement and the other Transaction Documents.

 

(j)           
The Purchaser and the Issuer shall consult with each other in issuing any press releases or otherwise making public statements
with respect to the transactions contemplated hereby, except that no consultation shall be required if such disclosure is required by
law or the rules and regulations of the SEC.

 

(k)           Each party
shall do and perform, or cause to be done and performed, all such further acts and things, and shall execute and deliver all such other
agreements, certificates, instruments and documents, as the other party may reasonably request in order to carry out the intent and accomplish
the purposes of this Agreement and the other Transaction Documents and the consummation of the transactions contemplated hereby and thereby.

 

 

 

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(l)           
The language used in this Agreement will be deemed to be the language chosen by the parties to express their mutual intent, and
no rules of strict construction will be applied against any party, as the parties mutually agree that each has had a full and fair opportunity
to review this Agreement and the other Transaction Documents and seek the advice of counsel on it and them.

 

(m)         
The Purchaser and the Issuer each shall have all rights and remedies set forth in this Agreement and all rights and remedies which
such holders have been granted at any time under any other agreement or contract and all of the rights which the Purchaser has by law.
Any person having any rights under any provision of this Agreement shall be entitled to enforce such rights specifically (without posting
a bond or other security), to recover damages by reason of any default or breach of any provision of this Agreement, including the recovery
of reasonable attorneys’ fees and costs, and to exercise all other rights granted by law.

 

(n)         
This Agreement shall be governed by and construed in accordance with the laws of the State of California applicable to contracts
made and to be performed wholly within such state.

 

 

 

 

 

 

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IN WITNESS WHEREOF the Purchasers
and the Issuer have executed this Agreement as of the date first above written.

 

THE ISSUER

 

QS ENERGY, INC.

 

 

By:__________________________

Cecil
Bond Kyte

Its: Chief Executive Officer

 

 

THE PURCHASER

 

 

	
    _______________________________

    Name (signature)
	 	
    _______________________________

    Amount of Commitment

    (U.S. Dollars)

	 	 	 
	
    _______________________________

    Print Name
	 	
    _______________________________

    Date

	 	 	 
	
    _______________________________

    Address
	 	 
	 	 	 
	
    _______________________________

    Address
	 	 
	 	 	 
	
    _______________________________

    Phone Number
	 	 
	 	 	 
	
    _______________________________

    Fax Number
	 	 
	 	 	 
	
    _______________________________

    Social Security Number
	 	 
	 	 	 
	
    _______________________________

    E-mail Address
	 	 

 

 

 

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EXHIBIT A

 

CONVERTIBLE NOTE

  

THE SECURITIES EVIDENCED BY THIS NOTE HAVE
NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR QUALIFIED FOR SALE UNDER ANY STATE SECURITIES LAWS (COLLECTIVELY,
“SECURITIES LAWS”) AND MAY NOT BE OFFERED, SOLD OR OTHERWISE TRANSFERRED UNLESS REGISTERED OR QUALIFIED FOR SALE UNDER ALL
APPLICABLE SECURITIES LAWS OR UNLESS, IN THE OPINION OF COUNSEL SATISFACTORY TO THE ISSUER, IN FORM AND SUBSTANCE SATISFACTORY TO THE
ISSUER, ANY SUCH OFFER, SALE OR OTHER TRANSFER IS EXEMPT FROM THE REGISTRATION OR QUALIFICATION REQUIREMENTS OF SUCH SECURITIES LAWS.

 

	$__________	_____________, 2021 (“Issuance Date”)

 

FOR VALUE RECEIVED, QS
ENERGY, INC., a corporation organized under the laws of the State of Nevada (the “Company”), promises to pay to the order
of ____________________________ “Investor”, as that term is defined on the Acknowledgement and Acceptance page of this Convertible
Note (“Note”) (hereafter, together with any subsequent holder hereof, called “Holder”), at “Investor’s
Address,” as that term is set forth on such page or at such other place as Holder may direct, the amount noted above, payable in
full Twelve (12) Months from the Issuance Date (the “Maturity Date”).

 

If this Note is not paid in
full on or prior to the Maturity Date the remaining balance shall be increased by 10% and the Company shall pay interest thereon at the
rate of 10% per annum until all sums due hereunder are paid in full.

 

Payments of both principal
and interest will be made in immediately available funds in lawful money of the United States of America to the Holder at the Investor’s
Address.

 

This Note is subject to the
following additional provisions:

 

1. The Company shall be entitled
to withhold from all payments of principal and/or interest of this Note any amounts required to be withheld under the applicable provisions
of the U.S. Internal Revenue Code of 1986, as amended, or other applicable laws at the time of such payments.

 

2. This Note has been
issued subject to representations, warranties and covenants of the original Holder hereof as contained in that certain Securities Purchase
Agreement (“Agreement”) of even date herewith, and subject to all restrictions, terms, conditions and disclosures in the Agreement,
and may be transferred or exchanged only in compliance with the Securities Act of 1933, as amended, and applicable state and other securities
laws. Prior to the due presentment for such transfer of this Note, the Company and any agent of the Company may treat the person in whose
name this Note is duly registered on the Company's Note register as the owner hereof for the purpose of receiving payment as herein provided
and all other purposes, whether or not this Note is overdue, and neither the Company nor any such agent shall be affected by notice to
the contrary. The transferee shall be bound, as the original Holder, by the same representations and terms described herein and under
the Agreement.

 

3. The Holder may, at
such Holder’s option, at any time while any sums are outstanding and unpaid hereunder, convert the then-outstanding principal amount
of this Note or any portion thereof, and any interest and any penalties accrued and unpaid thereon (the “Conversion Amount”),
into a number shares of fully paid and nonassessable Common Stock of the Company (the “Conversion Shares”) pursuant to the
following formula: the Conversion Amount divided by $0.03 (the “Conversion Price”). The Holder may exercise the right to convert
all or any portion of the Conversion Amount by delivering to the Company (i) an executed and completed notice of conversion in the form
attached to this Note (the "Notice of Conversion") to the Company and (ii) this Note. The business day on which a Notice of
Conversion and this Note are delivered to the Company in accordance with the provisions hereof shall be deemed a "Conversion Date.”
The Company will transmit the certificates representing Conversion Shares issuable upon such conversion of this Note within a reasonable
time after the Conversion Date to the Holder electronically through the Company’s transfer agent by means of a direct registration
system (“DRS”). Physical stock certificates will be issued upon written request subject to shipping cost paid by holder of
the Shares. No fractional shares shall be issued upon conversion of this Note. The amount of any of the Conversion Amount which is less
than a whole share of Common Stock shall be paid to the Holder in cash. Any delay due to such circumstance shall not be an event of default
under this Note.

  

 

 

    	 	10	 

     

    

 

4. The principal amount of
this Note, and any accrued interest thereon, shall be reduced as per that principal amount indicated on the Notice of Conversion upon
the proper receipt by the Holder of such Conversion Shares due upon such Notice of Conversion.

 

5. The number of Conversion
Shares shall be adjusted as follows:

 

a. If the Company shall
at any time after the Issuance Date subdivide its outstanding shares of Common Stock into a greater number of shares of Common Stock,
the number of Conversion Shares in effect immediately prior to such subdivision shall be proportionately increased, and conversely, in
case the outstanding shares of Common Stock shall be combined into a smaller number of shares of Common Stock, the Conversion Price in
effect immediately prior to such combination shall be proportionately reduced.

 

b.       If
the Company shall at any time or from time to time after the Issuance Date makes, or fixes a record date for the determination of holders
of Common Stock entitled to receive, a dividend or other distribution payable in additional shares of Common Stock, then and in each such
event the number of Conversion Shares issuable upon conversion of this Note shall be proportionately increased; provided, however, that
if such record date is fixed and such dividend is not fully paid, or if such distribution is not fully made on the date fixed therefor,
the number of Conversion Shares shall be recomputed to reflect that such dividend was not fully paid or that such distribution was not
fully made.

 

c.       If
Company at any time or from time to time after the Issuance Date makes, or fixes a record date for the determination of holders of Common
Stock entitled to receive, a dividend or other distribution payable in securities of Company other than shares of Common Stock, then and
in each such event provision shall be made so that Holder shall receive upon exercise of the conversion right of this Note, in addition
to the number of shares of Common Stock receivable thereupon, the amount of securities of Company which Holder would have received had
the Conversion Amount of this Note been exercised on the date of such event and had it thereafter, during the period from the date of
such event to and including the date of conversion or purchase, retained such securities receivable during such period.

 

d.       If
the Common Stock issuable upon the conversion of this Note or option to purchase is changed into the same or a different number of shares
of any class or classes of stock, whether by recapitalization, reclassification or otherwise (other than a transaction described elsewhere
in Section 5 of this Note), then, and in any such event, each Holder shall have the right thereafter, upon conversion of this Note or
purchase pursuant to option to receive the kind and amount of stock and other securities and property receivable upon such reorganization
or other change, in an amount equal to the amount that Holder would have been entitled to had it immediately prior to such reorganization,
reclassification or change converted this Note, but only to the extent this Note is actually converted, all subject to further adjustment
as provided herein.

 

6. No provision of this
Note shall alter or impair the obligation of the Company, which is absolute and unconditional, upon an Event of Default (as defined below),
to pay the principal of, and interest on this Note at the place, time, and rate, and in the coin or currency herein prescribed.

 

a. Events of Default. Each
of the following occurrences is hereby defined as an “Event of Default:”

 

Nonpayment.
The Company shall fail to make any payment of principal, interest, or other amounts payable hereunder when and as due; or

 

Dissolutions,
etc. The Company or any subsidiary shall fail to comply with any provision concerning its existence or any prohibition against dissolution,
liquidation, merger, consolidation or sale of assets; or

 

Noncompliance
with this Agreement. The Company shall fail to comply in any material respect with any provision hereof, which failure does not otherwise
constitute an Event of Default; or

 

Insolvency.
The institution of bankruptcy, insolvency, reorganization or liquidation proceedings or other proceedings for relief under any bankruptcy
law or any law for the relief of debtors shall be instituted by or against Company, which proceedings shall not have been vacated by appropriate
court order within sixty (60) days of such institution.

 

 

 

    	 	11	 

     

    

 

If one or more "Events
of Default" shall occur, then, or at any time thereafter, and in each and every such case, unless such Event of Default shall have
been waived in writing by the Holder (which waiver shall not be deemed to be a waiver of any subsequent default) or cured as provided
herein, at the option of the Holder, and in the Holder's sole discretion, the Holder may elect to consider this Note (and all interest
through such date) immediately due and payable. In order to so elect, the Holder must deliver written notice of the election and the amount
due to the Company via certified mail, return receipt requested, at the Company’s address as set forth herein (or any other address
provided to the Holder), and thereafter the Company shall have thirty (30) business days upon receipt to cure the Event of Default or
pay this Note, or convert the amount due on the Note pursuant to the conversion formula set forth above.

 

7. In case any provision
of this Note is held by a court of competent jurisdiction to be excessive in scope or otherwise invalid or unenforceable, such provision
shall be adjusted rather than voided, if possible, so that it is enforceable to the maximum extent possible, and the validity and enforceability
of the remaining provisions of this Note will not in any way be affected or impaired thereby.

 

8. This Note does not entitle
the Holder hereof to any voting rights or other rights as a shareholder of the Company prior to the conversion into Common Stock thereof,
except as provided by applicable law. If, however, at the time of the surrender of this Note and conversion the Holder hereof shall be
entitled to convert this Note, the Conversion Shares so issued shall be and be deemed to be issued to such holder as the record owner
of such shares as of the close of business on the Conversion Date.

 

9. The Holder shall pay all
issue and transfer taxes and other incidental expenses in respect of the issuance of certificates for Conversion Shares upon the conversion
of this Note, and such certificates shall be issued in the name of the Holder of this Note.

 

10. This Note may be prepaid
in whole or in part at any time or from time to time without premium or penalty upon 10 days’ prior written notice from the Company
to the Holder.

 

11. Upon receipt by the Company
of evidence reasonably satisfactory to it of the loss, theft, destruction or mutilation of this Note, and in case of loss, theft or destruction
of this Note, upon delivery of an indemnity agreement or security reasonably satisfactory in form and amount to the Company or, in the
case of any such mutilation, upon surrender and cancellation of such Note, and upon reimbursement to the Company of all reasonable expenses
incidental thereto, the Company will make and deliver to the Holder, in lieu thereof, a new Note in substantially identical form.

  

12.       If
the last or appointed day for the taking of any action or the expiration of any right required or granted herein shall be a Saturday or
a Sunday or shall be a legal holiday in the United States or the State of California, then such action may be taken or such right may
be exercised on the next succeeding business day.

 

13. (a)This Note shall
be governed by and construed in accordance with the laws of the State of California applicable to contracts made and to be performed wholly
within such state.

 

 

(b)Except as otherwise
provided herein, any notice or demand which, by the provisions hereof, is required or which may be given to or served upon the parties
hereto shall be in writing and, if by e-mail or facsimile transmission, shall be deemed to have been validly served, given or delivered
when sent, and if by personal delivery, shall be deemed to have been validly served, given or delivered upon actual delivery and, if mailed,
shall be deemed to have been validly served, given or delivered three (3) business days after deposit in the United States mails, as registered
or certified mail, with proper postage prepaid and addressed to the party or parties to be notified.

 

(c)       The
Holder acknowledges that the Conversion Shares acquired upon the exercise of this Note will have restrictions upon its resale imposed
by state and federal securities laws, together with other restrictions, terms, conditions and disclosures as fully set forth in the Agreement.

 

(d)       With
regard to any power, remedy or right provided herein or otherwise available to any party hereunder (i) no waiver or extension of time
shall be effective unless expressly contained in a writing signed by the waiving party; and (ii) no alteration, modification or impairment
shall be implied by reason of any previous waiver, extension of time, delay or omission in exercise, or other indulgence.

 

(e)       
This Note may not be amended, altered or modified except by a writing signed by the Company and the Holder. 

 

 

 

    	 	12	 

     

    

 

IN WITNESS WHEREOF, the Company has caused this
Convertible Note to be duly executed by an officer thereunto duly authorized.

 

QS ENERGY, INC.

3606 Challenger Way, Unit #1

Carson City, NV 89706

 

 

 

By ____________________________

Name: Cecil Bond Kyte

Title:   Chief Executive Officer

 

 ACKNOWLEDGED AND ACCEPTED:

 

 

 

 

_______________________________

Investor Name (Signature)

 

 

_______________________________

Print Name

 

_______________________________

 

_______________________________

Investor Address

 

 

 

 

 

 

 

 

 

 

 

    	 	13	 

     

    

 

NOTICE OF EXERCISE OF CONVERSION RIGHT 

 

	TO:	(Company Name)

 

(1)       The
undersigned hereby elects to convert $______________ of the attached Note into ______________ shares of Common Stock (the "Shares")
of QS Energy, Inc. (“Company”) pursuant to the terms of the attached Note.

 

(2)       Please
issue a certificate or certificates representing the Shares in the name of the undersigned or in such other name as is specified below:

 

	 	
    _______________________________________________

    (Print Name)

     

    Address:

    _______________________________________________

    _______________________________________________

    _______________________________________________
	 

  

(3) The Company shall issue the Shares electronically
through its transfer agent by means of a direct registration system (“DRS”)1.
Physical stock certificates will be issued upon written request subject to shipping cost paid by holder of the Shares.

 

(4) The undersigned confirms that the Shares are
being acquired for the account of the undersigned for investment only and not with a view to, or for resale in connection with, the distribution
thereof and that the undersigned has no present intention of distributing or selling the Shares.

 

(5) The undersigned accepts such shares subject
to the restrictions on transfer and other terms, conditions and disclosures set forth in the attached Note and set forth in that certain
Securities Purchase Agreement between the Company and the undersigned dated as of the date of the attached Note.

 

 

 

	
    __________________________

    (Date)
	
    __________________________

    (Signature)

	 	 
	 	
    __________________________

    (Print Name)

 

________________________

 

1
The Company’s transfer agent, Nevada Agency and Transfer Company (“NATCO”) is a participant in the Depository
Trust Company’s FAST program. The FAST program allows NATCO to provide DWAC (deposit/withdrawal at custodian) and DRS (direct registration
system) services to the Company and its shareholders. This eliminates the risk of lost certificates and courier fees by providing electronic
transfers.

 

 

 

    	 	14	 

     

    

 

EXHIBIT B

 

STOCK PURCHASE WARRANT

 

THIS WARRANT AND ANY SHARES ISSUED UPON
ITS EXERCISE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE "ACT"), AND HAVE BEEN ACQUIRED
FOR INVESTMENT AND NOT WITH VIEW TO, OR IN CONNECTION WITH, THE SALE OR DISTRIBUTION THEREOF. NO SUCH SALE OR DISPOSITION OF ANY SHARES
ISSUED UPON EXERCISE HEREOF MAY BE AFFECTED WITHOUT AN EFFECTIVE REGISTRATION STATEMENT RELATED THERETO OR AN OPINION OF COUNSEL SATISFACTORY
IN FORM AND SUBSTANCE TO THE COMPANY THAT SUCH REGISTRATION IS NOT REQUIRED UNDER THE ACT. THE TRANSFER OF THIS WARRANT IS RESTRICTED
AS SET FORTH HEREIN.

 

	No. ______	______________, 2021

 

 

QS ENERGY, INC.

WARRANT TO PURCHASE COMMON STOCK

 

VOID AFTER 5:00 P.M. (Pacific Time) ON ______________,
2022

 

THIS CERTIFIES that, for
the value received, the holder identified on the last page of this Warrant __________________________ (the "Holder") is entitled,
upon the terms and subject to the conditions hereinafter set forth, at any time on or after the date of this Warrant and on or prior to
5:00 p.m. P.S.T. on the first anniversary of the date of this Warrant (the "Expiration Time"), but not thereafter, to subscribe
for and purchase, from QS ENERGY, INC., a Nevada corporation (the "Company"), up to ________________ (#) shares of the Company's
Common Stock (the "Shares") at a purchase price per share equal to $0.04 (the "Exercise Price").

 

1.       Exercise
of Warrant.

 

The purchase rights represented
by this Warrant are exercisable by the Holder, in whole or in part, at any time after the date of this Warrant and before the Expiration
Time by the surrender of this Warrant and the Notice of Exercise annexed hereto duly executed at the office of the Company, in Carson
City, Nevada (or such other office or agency of the Company as it may designate by notice in writing to the Holder at the address of the
Holder appearing on the books of the Company), and upon payment of an amount equal to the aggregate Exercise Price for the number of Shares
thereby purchased (by cash or by check or certified bank check payable to the order of the Company in an amount equal to the purchase
price of the shares thereby purchased); whereupon the Holder shall be entitled to receive a stock certificate representing the number
of Shares so purchased. The Company agrees that if at the time of the surrender of this Warrant and purchase of the Shares, and the Holder
shall be entitled to exercise this Warrant, the Shares so purchased shall be and be deemed to be issued to such holder as the record owner
of such Shares as of the close of business on the date on which this Warrant shall have been exercised as aforesaid.

 

Upon partial exercise of this
Warrant, the Holder shall be entitled to receive from the Company a new Warrant in substantially identical form for the purchase of that
number of Shares as to which this Warrant shall not have been exercised. Certificates for Shares purchased hereunder shall be delivered
to the Holder within a reasonable time after the date on which this Warrant shall have been exercised as aforesaid.

  

2. No Fractional Shares
or Scrip. No fractional shares or scrip representing fractional shares shall be issued upon the exercise of this Warrant. With respect
to any fraction of a share called for upon the exercise of this Warrant, an amount equal to such fraction multiplied by the Exercise Price
shall be paid in cash to the Holder.

 

 

 

    	 	15	 

     

    

 

3. Charges, Taxes and
Expenses. The Holder shall pay all issue and transfer taxes and other incidental expenses in respect of the issuance of certificates
for Shares upon the exercise of this Warrant, and such certificates shall be issued in the name of the Holder of this Warrant.

 

4. No Rights as a Stockholder.
This Warrant does not entitle the Holder to any voting rights or other rights as a stockholder of the Company prior to the exercise hereof.

 

5. Loss, Theft, Destruction
or Mutilation of Warrant. Upon receipt by the Company of evidence reasonably satisfactory to it of the loss, theft, destruction or
mutilation of this Warrant, and in case of loss, theft or destruction of this Warrant, upon delivery of an indemnity agreement or security
reasonably satisfactory in form and amount to the Company or, in the case of any such mutilation, upon surrender and cancellation of such
Warrant, and upon reimbursement to the Company of all reasonable expenses incidental thereto, the Company will make and deliver to the
Holder, in lieu thereof, a new Warrant in substantially identical form and dated as of such cancellation.

 

6. Saturdays, Sundays,
Holidays, etc. If the last or appointed day for the taking of any action or the expiration of any right required or granted herein
shall be a Saturday or a Sunday or shall be a legal holiday in the United States or the State of California, then such action may be taken
or such right may be exercised on the next succeeding business.

 

7. Merger, Reclassification,
etc.

 

(a) Merger, etc. If at
any time the Company proposes (A) the acquisition of the Company by another entity by means of any transaction or series of related transactions
(including, without limitation, any reorganization, merger, consolidation or stock issuance) that results in the transfer of fifty percent
(50%) or more of the then outstanding voting power of the Company; or (B) a sale of all or substantially all of the assets of the Company,
then the Company shall give the Holder ten (10) days notice of the proposed effective date of the transaction. If, in the case of such
acquisition of the Company, and the Warrant has not been exercised by the effective date of the transaction, this Warrant shall be exercisable
into the kind and number of shares of stock or other securities or property of the Company or of the entity resulting from such merger
or acquisition to which such Holder would have been entitled if immediately prior to such acquisition or merger, it had exercised this
Warrant. The provisions of this Section 7(a) shall similarly apply to successive consolidations, mergers, sales or conveyances.

  

(b) Reclassification, etc.
If the Company at any time shall, by subdivision, combination or reclassification of securities or otherwise, change any of the securities
to which purchase rights under this Warrant exist into the same or a different number of securities of any class or classes, this Warrant
shall thereafter be to acquire such number and kind of securities as would have been issuable as the result of such change with respect
to the securities which were subject to the purchase rights under this Warrant immediately prior to such subdivision, combination, reclassification
or other change. If the Shares are subdivided or combined into a greater or smaller number of Shares, the Exercise Price under this Warrant
shall be proportionately reduced in case of subdivision of shares or proportionately increased in the case of combination of shares, in
both cases by the ratio which the total number of Shares to be outstanding immediately after such event bears to the total number of Shares
outstanding immediately prior to such event.

 

(c) Cash Distributions.
No adjustment on account of cash dividends or interest on the Shares or other securities purchasable hereunder will be made to the Exercise
Price under this Warrant.

 

8. Restrictions on Transfer.

 

(a) Restrictions on Transfer
of Shares. In no event will the Holder make a disposition of this Warrant or the Shares unless and until, if requested by the Company,
it shall have furnished the Company with an opinion of counsel satisfactory to the Company and its counsel to the effect that appropriate
action necessary for compliance with the Securities Act of 1933, as amended (the "Act") relating to sale of an unregistered
security has been taken. Notwithstanding the foregoing, the restrictions imposed upon the transferability of the Shares shall terminate
as to any particular Share when (i) such security shall have been sold without registration in compliance with Rule 144 under the Act,
or (ii) a letter shall have been issued to the Holder at its request by the staff of the Securities and Exchange Commission or a ruling
shall have been issued to the Holder at its request by such Commission stating that no action shall be recommended by such staff or taken
by such Commission, as the case may be, if such security is transferred without registration under the Act in accordance with the conditions
set forth in such letter or ruling and such letter or ruling specifies that no subsequent restrictions on transfer are required, or (iii)
such security shall have been registered under the Act and sold by the Holder thereof in accordance with such registration.

 

 

 

    	 	16	 

     

    

 

(b) Subject to the provisions
of Section 8(a) hereof, this Warrant and all rights hereunder are transferable, in whole or in part, upon surrender of the Warrant with
a properly executed assignment at the principal office of the Company.

 

(c) Restrictive Legends.
The stock certificates representing the Shares and any securities of the Company issued with respect thereto shall be imprinted with legends
restricting transfer except in compliance with the terms hereof and with applicable federal and state securities laws substantially as
follows:

 

“THE SHARES REPRESENTED BY THIS
CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AND MAY NOT BE SOLD, TRANSFERRED, PLEDGED OR OTHERWISE DISPOSED
OF IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 1933 OR AN OPINION OF COUNSEL SATISFACTORY TO THE
ISSUER OF THIS CERTIFICATE THAT REGISTRATION IS NOT REQUIRED UNDER SAID ACT”.

 

9. Miscellaneous.

 

(a) Governing Law. This
Warrant shall be governed by and construed in accordance with the laws of the State of California applicable to contracts made and to
be performed wholly within such state.

 

(b) Restrictions. The
Holder acknowledges that the Shares acquired upon the exercise of this Warrant will have restrictions upon its resale imposed by state
and federal securities laws.

 

(c) Waivers Strictly Construed.
With regard to any power, remedy or right provided herein or otherwise available to any party hereunder (i) no waiver or extension of
time shall be effective unless expressly contained in a writing signed by the waiving party; and (ii) no alteration, modification or impairment
shall be implied by reason of any previous waiver, extension of time, delay or omission in exercise, or other indulgence.

 

(d) Modifications. This
Warrant may not be amended, altered or modified except by a writing signed by the Company and the Holder of this Warrant.

 

IN WITNESS WHEREOF, QS ENERGY,
INC. has caused this Warrant to be executed by its duly authorized representative dated as of the date first set forth above.

 

	
     

     

    Holder:

     

     

     

    _____________________

     
	
     

    QS ENERGY, INC.

    3606 Challenger Way, Unit #1

    Carson City, NV 89706

     

     

    By: __________________________

    Name:Cecil Bond Kyte

    Title:Chief Executive Officer

 

 

 

 

 

 

 

 

 

    	 	17	 

     

    

 

NOTICE OF EXERCISE

 

	TO:	QS ENERGY, INC., a Nevada corporation

 

(1)       The
undersigned hereby elects to purchase ______________ shares of Common Stock (the "Shares") of QS Energy, Inc. (“Issuer”)
pursuant to the terms of the attached Warrant, and tenders herewith payment of the purchase price in full, together with all applicable
transfer taxes, if any.

 

(2)        Please
issue a certificate or certificates representing the Shares in the name of the undersigned or in such other name as is specified below:

 

	
    Name:

    ________________________________

    (Print Name)

     
	
    Address:

     ______________________________

     ______________________________

     ______________________________

 

(3) The Company shall issue the Shares electronically
through its transfer agent by means of a direct registration system (“DRS”)1. Physical stock certificates will
be issued upon written request subject to shipping cost paid by holder of the Shares.

 

(4) The undersigned confirms
that he is an “accredited investor” as defined by Rule 501(a) under the Securities Act of 1933, as amended, at the time of
execution of this Notice.

 

(5)       The
undersigned confirms that the Shares are being acquired for the account of the undersigned for investment only and not with a view to,
or for resale in connection with, the distribution thereof and that the undersigned has no present intention of distributing or selling
the Shares.

 

(6)       The
undersigned accepts such Shares subject to the restrictions on transfer set forth in the attached Warrant.

 

(7)       The
undersigned acknowledges that the Issuer has given it access to all information relating to the Issuer’s business that the undersigned
has requested. The undersigned has reviewed all materials relating to the Issuer’s business, financial condition and operations
which it has requested and the undersigned has reviewed all of such materials as the undersigned, in the undersigned’s sole and
absolute discretion has deemed necessary or desirable. The undersigned has had an opportunity to ask questions of and discuss the business,
management and financial affairs of the Issuer with the Issuer’s management. Specifically but not by way of limitation, the undersigned
acknowledges the Issuer’s publicly available filings made periodically with the SEC, which filings are available at www.sec.gov,
and which filings the undersigned acknowledges reviewing or having had the opportunity of reviewing.

 

(8)       The
undersigned acknowledges that it has, by reason of its business and financial experience, such knowledge, sophistication and experience
in financial and business matters and in making investment decisions of this type that it is capable of (i) evaluating the merits and
risks of an investment in the Shares and making an informed investment decision in connection therewith; (ii) protecting its own interest;
and (iii) bearing the economic risk of such investment for an indefinite period of time for shares which are not transferable or freely
tradable. The undersigned hereby agrees to indemnify the Issuer and the officers, directors and employees thereof harmless against all
liability, costs or expenses (including reasonable attorneys’ fees) arising by reason of or in connection with any misrepresentation
or any breach of warranties or representations of the undersigned contained in this Notice, or arising as a result of the sale or
distribution of the Shares issuable upon exercise of the Warrants. The representations and warranties contained herein shall be binding
upon the heirs, legal representatives, successors and assigns of the undersigned.

 

	
    ________________________

    (Date)
	
    ___________________________________

    (Signature)

    ___________________________________

    (Print Name)

 

__________________________________

 

1 The Company’s transfer
agent, Nevada Agency and Transfer Company (“NATCO”) is a participant in the Depository Trust Company’s FAST program.
The FAST program allows NATCO to provide DWAC (deposit/withdrawal at custodian) and DRS (direct registration system) services to the
Company and its shareholders. This eliminates the risk of lost certificates and courier fees by providing electronic transfers.

 

 

 

    	 	18Document

     
EXHIBIT 10.1

ESTABLISHMENT LABS HOLDINGS INC.
INDEMNIFICATION AGREEMENT

This Indemnification Agreement (this “Agreement”) is dated as of [DATE] (the “Effective Date”), and is between Establishment Labs Holdings Inc., a company incorporated under the laws of the British Virgin Islands (the “Company”), and [NAME]  (“Indemnitee”).

RECITALS

A.        Indemnitee’s service to the Company substantially benefits the Company.
B.         Individuals are reluctant to serve as directors or officers of companies or in certain other capacities unless they are provided with adequate protection through insurance or indemnification against the risks of claims and actions against them arising out of such service.
C.         Indemnitee does not regard the protection currently provided by applicable law, the Company’s governing documents and any insurance as adequate under the present circumstances, and Indemnitee may not be willing to serve as a director or officer without additional protection.
D.        In order to induce Indemnitee to continue to provide services to the Company, it is reasonable, prudent and necessary for the Company to contractually obligate itself to indemnify, and to advance expenses on behalf of, Indemnitee as permitted by applicable law.
E.         This Agreement is a supplement to and in furtherance of the indemnification provided in the Company’s memorandum and articles of association and applicable law, and any resolutions adopted pursuant thereto, and this Agreement shall not be deemed a substitute therefor, nor shall this Agreement be deemed to limit, diminish or abrogate any rights of Indemnitee thereunder.
The parties therefore agree as follows:
1.Definitions. 
a.“BVI Law” means the applicable laws of the British Virgin Islands.
b.  A “Change in Control” shall be deemed to occur upon the earliest to occur after the date of this Agreement of any of the following events:
i.Acquisition of Shares by Third Party. Any Person (as defined below) becomes the Beneficial Owner (as defined below), directly or indirectly, of shares of the Company representing fifteen percent (15%) or more of the combined voting power of the Company’s then outstanding shares; provided, however, that the foregoing shall not include any Person having such status prior to the consummation of the initial public offering of the Company’s shares unless after the initial public offering such Person is or becomes the Beneficial Owner, directly or indirectly, of additional 

shares of the Company representing in the aggregate an additional five percent (5%) or more of the combined voting power of the Company’s then outstanding shares;

1.Change in Board Composition. During any period of two consecutive years (not including any period prior to the execution of this Agreement), individuals who at the beginning of such period constitute the Company’s board of directors, and any new directors (other than a director designated by a person who has entered into an agreement with the Company to effect a transaction described in Sections 1(a)(i), 1(a)(iii) or 1(a)(iv)) whose election by the board of directors or nomination for election by the Company’s shareholders was approved by a vote of at least two-thirds of the directors then still in office who either were directors at the beginning of the period or whose election or nomination for election was previously so approved, cease for any reason to constitute at least a majority of the members of the Company’s board of directors;
2.Corporate Transactions. The effective date of a merger or consolidation of the Company with any other entity, other than a merger or consolidation which would result in the voting shares of the Company outstanding immediately prior to such merger or consolidation continuing to represent (either by remaining outstanding or by being converted into voting shares of the surviving entity) more than 50% of the combined voting power of the voting shares of the surviving entity outstanding immediately after such merger or consolidation and with the power to elect at least a majority of the board of directors or other governing body of such surviving entity;
3.Liquidation. The approval by the shareholders of the Company of a complete liquidation of the Company or an agreement for the sale or disposition by the Company of all or substantially all of the Company’s assets; and
4.Other Events. Any other event of a nature that would be required to be reported in response to Item 6(e) of Schedule 14A of Regulation 14A (or in response to any similar item on any similar schedule or form) promulgated under the Securities Exchange Act of 1934, as amended, whether or not the Company is then subject to such reporting requirement.
For purposes of this Section 1(a), the following terms shall have the following meanings:

1.“Person” shall have the meaning as set forth in Sections 13(d) and 14(d) of the Securities Exchange Act of 1934, as amended; provided, however, that “Person” shall exclude (i) the Company, (ii) any trustee or other fiduciary holding shares under an employee benefit plan of the Company, and (iii) any corporation owned, directly or indirectly, by the shareholders of the Company in substantially the same proportions as their ownership of shares of the Company.
2.“Beneficial Owner” shall have the meaning given to such term in Rule 13d-3 under the Securities Exchange Act of 1934, as amended; provided, however, that “Beneficial Owner” shall exclude any Person otherwise becoming a Beneficial Owner by reason of (i) the shareholders of the Company approving a merger of the Company with another entity or (ii) the Company’s board of directors approving a sale of shares by the Company to such Person.

c.“Corporate Status” describes the status of a person who is or was a director, trustee, general partner, managing member, officer, employee, agent or fiduciary of the Company or any other Enterprise.
d. “Disinterested Director” means a director of the Company who is not and was not a party to the Proceeding in respect of which indemnification is sought by Indemnitee.
e.“Enterprise” means the Company and any other corporation, partnership, limited liability company, joint venture, trust, employee benefit plan or other enterprise of which Indemnitee is or was serving at the request of the Company as a director, trustee, general partner, managing member, officer, employee, agent or fiduciary.
f.“Expenses” include all direct and indirect costs, fees and expenses of any type or nature whatsoever, including, without limitation, all reasonable and actually incurred attorneys’ fees and costs, retainers, court costs, transcript costs, fees and costs of experts, witness fees, travel expenses, fees of private investigators and professional advisors, e-discovery costs, duplicating costs, printing and binding costs, telephone charges, postage, delivery service fees, corporate secretarial services, and all other disbursements or expenses of the types customarily incurred in connection with prosecuting, defending, preparing to prosecute or defend, investigating, being or preparing to be a deponent or witness in, or otherwise participating in, a Proceeding, including reasonable compensation for time spent by the Indemnitee for which he or she is not otherwise compensated by the Company or any third party. Expenses also include (i) Expenses incurred in connection with any appeal resulting from any Proceeding, including without limitation the premium, security for, and other costs relating to any cost bond, supersedeas bond or other appeal bond or their equivalent, and (ii) for purposes of Section 12(d), Expenses incurred by Indemnitee in connection with the interpretation, enforcement or defense of Indemnitee’s rights under this Agreement or under any directors’ and officers’ liability insurance policies maintained by the Company. Expenses, however, shall not include amounts paid in settlement by Indemnitee or the amount of judgments or fines against Indemnitee.
g.“Independent Counsel” means a reputable law firm, or a partner or member of a law firm, that is experienced in matters of corporation law and neither presently is, nor in the past five years has been, retained to represent (i) the Company or Indemnitee in any matter material to either such party (other than as Independent Counsel with respect to matters concerning Indemnitee under this Agreement, or other indemnitees under similar indemnification agreements), or (ii) any other party to the Proceeding giving rise to a claim for indemnification hereunder. Notwithstanding the foregoing, the term “Independent Counsel” shall not include any person who, under the applicable standards of professional conduct then prevailing, would have a conflict of interest in representing either the Company or Indemnitee in an action to determine Indemnitee’s rights under this Agreement.
h.“Proceeding” means any threatened, pending or completed action, suit, arbitration, mediation, alternate dispute resolution mechanism, investigation, inquiry, administrative hearing or proceeding, whether brought in the right of the Company, a Subsidiary or otherwise and whether of a civil, criminal, administrative or investigative nature, including any appeal therefrom and including without limitation any such Proceeding pending as of the date of this Agreement, in which Indemnitee was, is or will be involved as a party, a potential party, a non-party witness or otherwise by reason of (i) the fact that Indemnitee is or was a director or officer of the Company or of a Subsidiary, (ii) any action taken by 

Indemnitee or any action or inaction on Indemnitee’s part while acting as a director or officer of the Company, or (iii) the fact that he or she is or was serving at the request of the Company, or of a Subsidiary as a director, trustee, general partner, managing member, officer, employee, agent or fiduciary of the Company, a Subsidiary or any other Enterprise, in each case whether or not serving in such capacity at the time any liability or Expense is incurred for which indemnification or advancement of expenses can be provided under this Agreement.
i.“Subsidiary” means any entity of which more than 50% of the outstanding voting shares or voting equity interest is owned directly or indirectly by the Company.
j.Reference to “other enterprises” shall include employee benefit plans; references to “fines” shall include any excise taxes assessed on a person with respect to any employee benefit plan; references to “serving at the request of the Company” shall include any service as a director, officer, employee or agent of the Company or of a Subsidiary which imposes duties on, or involves services by, such director, officer, employee or agent with respect to an employee benefit plan, its participants or beneficiaries; and a person who acted in good faith and in a manner he or she reasonably believed to be in the best interests of the participants and beneficiaries of an employee benefit plan shall be deemed to have acted in a manner “not opposed to the best interests of the Company” as referred to in this Agreement.
2.Indemnity in Third-Party Proceedings. The Company shall indemnify, defend and hold Indemnitee harmless in accordance with the provisions of this Section 2 if Indemnitee was, is, or is threatened to be made, a party to or a participant in any Proceeding, other than a Proceeding by or in the right of the Company to procure a judgment in its favor. Pursuant to this Section 2, Indemnitee shall be indemnified to the fullest extent permitted by applicable law against all Expenses, judgments, fines and amounts paid in settlement (including all interest, penalties or finance charges accrued in connection therewith) actually and reasonably incurred by Indemnitee or on his or her behalf in connection with such Proceeding or any claim, issue or matter therein, if Indemnitee acted in good faith and in a manner he or she reasonably believed to be in or not opposed to the best interests of the Company and, with respect to any criminal action or proceeding, had no reasonable cause to believe that his or her conduct was unlawful. 
3.Indemnity in Proceedings by or in the Right of the Company. The Company shall indemnify Indemnitee in accordance with the provisions of this Section 3 if Indemnitee was, is, or is threatened to be made, a party to or a participant in any Proceeding by or in the right of the Company to procure a judgment in its favor. Pursuant to this Section 3, Indemnitee shall be indemnified to the fullest extent permitted by applicable law against all Expenses, judgments, fines and amounts paid in settlement (including all interest, penalties or finance charges accrued in connection therewith) actually and reasonably incurred by Indemnitee or on Indemnitee’s behalf in connection with such Proceeding or any claim, issue or matter therein, if Indemnitee acted in good faith and in a manner he or she reasonably believed to be in or not opposed to the best interests of the Company. No indemnification for Expenses shall be made under this Section 3 in respect of any claim, issue or matter as to which Indemnitee shall have been finally (following any appeals) adjudged by a court of competent jurisdiction to be liable to the Company, unless and only to the extent that the courts of the British Virgin Islands shall determine upon application that, despite the adjudication of liability but in view of all the circumstances of the case, 

Indemnitee is fairly and reasonably entitled to indemnification for such expenses as the courts of the British Virgin Islands shall deem proper.
4.Indemnification for Expenses of a Party Who is Wholly or Partly Successful. Notwithstanding any other provisions of this Agreement, to the extent that Indemnitee was or is a party to or a participant in and is successful (on the merits or otherwise) in defense of any Proceeding or any claim, issue or matter therein, in whole or in part, the Company shall, to the fullest extent permitted by applicable law, indemnify and hold Indemnitee harmless against all Expenses, judgments, fines and amounts paid in settlement (including all interest, penalties or finance charges accrued in connection therewith) actually and reasonably incurred by Indemnitee or on Indemnitee’s behalf in connection therewith and no determination of Indemnitee’s entitlement to indemnification (pursuant to Section 10 below) shall be required. For purposes of this Section 4, the termination of any claim, issue or matter in such a Proceeding by dismissal, with or without prejudice, shall be deemed to be a successful result as to such claim, issue or matter.
5.Indemnification for Expenses of a Witness. Notwithstanding any other provisions of this Agreement, to the extent that Indemnitee was or is, by reason of his or her Corporate Status, a witness or deponent in any Proceeding to which Indemnitee is not a party, Indemnitee shall be indemnified and held harmless to the fullest extent permitted by applicable law against all Expenses actually and reasonably incurred by Indemnitee or on Indemnitee’s behalf in connection therewith and no determination of Indemnitee’s entitlement to indemnification (pursuant to Section 10 below) shall be required.
6.Additional Indemnification.
a.Notwithstanding any limitation in Sections 2, 3 or 4, the Company shall indemnify and hold Indemnitee harmless to the fullest extent permitted by applicable law if Indemnitee was, is, or is threatened to be made, a party to or a participant in any Proceeding (including a Proceeding by or in the right of the Company to procure a judgment in its favor) against all Expenses, judgments, fines and amounts paid in settlement (including all interest, penalties or finance charges accrued in connection therewith) actually and reasonably incurred by Indemnitee or on his or her behalf in connection with the Proceeding or any claim, issue or matter therein.
b.For purposes of Section 6(a), the meaning of the phrase “to the fullest extent permitted by applicable law” shall include, but not be limited to:
i.the fullest extent permitted by the provision of the DGCL that authorizes or contemplates additional indemnification by agreement, or the corresponding provision of any amendment to or replacement of BVI Law; and
ii.the fullest extent authorized or permitted by any amendments to or replacements of BVI Law adopted after the date of this Agreement that increase the extent to which a corporation may indemnify its officers and directors.
7.Exclusions. Notwithstanding any provision in this Agreement, the Company shall not be obligated under this Agreement to make any indemnity in connection with any Proceeding (or any part of any Proceeding):

a.for which payment has actually been made to or on behalf of Indemnitee under any statute, insurance policy, indemnity provision, vote or otherwise, except with respect to any excess beyond the amount paid;
b.for an accounting or disgorgement of profits pursuant to Section 16(b) of the Securities Exchange Act of 1934, as amended, or similar provisions of federal, state or local statutory law or common law, if Indemnitee is held liable therefor (including pursuant to any settlement arrangements);
c.for any reimbursement of the Company by Indemnitee of any bonus or other incentive-based or equity-based compensation or of any profits realized by Indemnitee from the sale of shares of the Company, as required in each case under the Securities Exchange Act of 1934, as amended (including any such reimbursements that arise from an accounting restatement of the Company pursuant to Section 304 of the Sarbanes-Oxley Act of 2002 (the “Sarbanes-Oxley Act”), or Section 954 of the Dodd-Frank Wall Street Reform and Consumer Protection Act, or the payment to the Company of profits arising from the purchase and sale by Indemnitee of shares in violation of Section 306 of the Sarbanes-Oxley Act), if Indemnitee is held liable therefor (including pursuant to any settlement arrangements);
d.initiated by Indemnitee, including any Proceeding (or any part of any Proceeding) initiated by Indemnitee against the Company or its directors, officers, employees, agents or other indemnitees, unless (i) the Company’s board of directors authorized the Proceeding (or the relevant part of the Proceeding) prior to its initiation, (ii) the Company provides the indemnification, in its sole discretion, pursuant to the powers vested in the Company under applicable law, (iii) otherwise authorized in Section 12(d) or (iv) otherwise required by applicable law or the Company’s memorandum and articles of association; or
e.if prohibited by applicable law.
8.Advances of Expenses. Notwithstanding any provision of this Agreement to the contrary, the Company shall advance the Expenses incurred (or reasonably expected by Indemnitee to be incurred within three months) by Indemnitee in connection with any Proceeding prior to its final disposition, and such advancement shall be made as soon as reasonably practicable, but in any event no later than 15 days after the receipt by the Company of a written statement or statements requesting such advances from time to time (which shall include invoices, estimates or fee proposals received by Indemnitee in connection with such Expenses but, in the case of invoices in connection with legal services, any references to legal work performed or to expenditure made that would cause Indemnitee to waive any privilege accorded by applicable law shall not be included with the invoice). Advances shall include any and all reasonable Expenses incurred pursuing a Proceeding to enforce this right of advancement, including Expenses incurred preparing and forwarding statements to the Company to support the advances claimed. Advances shall be unsecured and interest free and made without regard to Indemnitee’s ability to repay such advances or Indemnitee’s ultimate entitlement to be indemnified under the other provisions of this Agreement. Indemnitee hereby undertakes to repay any advance to the extent that it is ultimately determined that Indemnitee is not entitled to be indemnified by the Company. This Section 8 shall not apply to the extent advancement is prohibited by law and shall not apply to any Proceeding (or any part of any Proceeding) for which indemnity is not permitted under this Agreement, but shall apply to any Proceeding (or any part of any Proceeding) referenced in Section 7(b) or 7(c) prior to a determination that Indemnitee is not entitled to be indemnified by the Company.

9.Procedures for Notification and Defense of Claim.
a.Indemnitee shall notify the Company in writing of any matter with respect to which Indemnitee intends to seek indemnification or advancement of Expenses as soon as reasonably practicable following the receipt by Indemnitee of notice thereof. The written notification to the Company shall include, in reasonable detail, a description of the nature of the Proceeding and the facts underlying the Proceeding. The failure by Indemnitee to notify the Company will not relieve the Company from any liability which it may have to Indemnitee hereunder or otherwise than under this Agreement, and any delay in so notifying the Company shall not constitute a waiver by Indemnitee of any rights. 
b.If, at the time of the receipt of a notice of a Proceeding pursuant to the terms hereof, the Company has directors’ and officers’ liability insurance in effect that may be applicable to the Proceeding, the Company shall give prompt notice of the commencement of the Proceeding to the insurers in accordance with the procedures set forth in the applicable policies. The Company shall thereafter take all commercially-reasonable action to cause such insurers to pay, on behalf of Indemnitee, all amounts payable as a result of such Proceeding in accordance with the terms of such policies.  
c.In the event the Company may be obligated to make any indemnity in connection with a Proceeding, the Company shall be entitled to assume the defense of such Proceeding except for such Proceeding brought by the Company or as to which the Indemnitee has reasonably concluded that there may be a conflict of interest between the Company and the Indemnitee with counsel approved by Indemnitee, which approval shall not be unreasonably withheld, conditioned or delayed, upon the delivery to Indemnitee of written notice of its election to do so. After delivery of such notice, approval of such counsel by Indemnitee and the retention of such counsel by the Company, the Company will not be liable to Indemnitee for any fees or expenses of counsel subsequently incurred by Indemnitee with respect to the same Proceeding. Notwithstanding the Company’s assumption of the defense of any such Proceeding, the Company shall be obligated to pay the fees and expenses of Indemnitee’s separate counsel to the extent (i) the employment of separate counsel by Indemnitee is authorized by the Company, (ii) counsel for the Company or Indemnitee shall have reasonably concluded that there is a conflict of interest between the Company and Indemnitee in the conduct of any such defense such that Indemnitee needs to be separately represented, (iii) the Company is not financially or legally able to perform its indemnification obligations or (iv) the Company shall not have retained, or shall not continue to retain, counsel to defend such Proceeding. Regardless of any provision in this Agreement, Indemnitee shall have the right to employ counsel in any Proceeding at Indemnitee’s personal expense. The Company shall not be entitled, without the consent of Indemnitee, to assume the defense of any claim brought by or in the right of the Company.
d.Indemnitee shall give the Company such information and cooperation in connection with the Proceeding as may be reasonably appropriate.
e.Except as set forth in this Agreement, the Company shall not be liable to indemnify Indemnitee for any settlement of any Proceeding (or any part thereof) by Indemnitee without the Company’s prior written consent, which shall not be unreasonably withheld, conditioned or delayed. 
f.The Company shall not settle any Proceeding (or any part thereof) in a manner that imposes any Expense, fine, penalty or liability on Indemnitee, or which does not provide for a full and final release of 

all claims asserted against Indemnitee, without Indemnitee’s prior written consent, which shall not be unreasonably withheld, conditioned or delayed. 
10.Procedures upon Application for Indemnification. 
a.To obtain indemnification, Indemnitee shall submit to the Company a written request, including therein or therewith such documentation and information as is reasonably available to Indemnitee and as is reasonably necessary to determine whether and to what extent Indemnitee is entitled to indemnification.  Any delay in providing the request will not relieve the Company from its obligations under this Agreement, except to the extent such failure is prejudicial.
b.Upon written request by Indemnitee for indemnification pursuant to Section 10(a), a determination with respect to Indemnitee’s entitlement thereto shall be made in the specific case (i) if a Change in Control shall have occurred, by Independent Counsel in a written opinion to the Company’s board of directors, a copy of which shall be delivered to Indemnitee or (ii) if a Change in Control shall not have occurred, (A) by a majority vote of the Disinterested Directors, even though less than a quorum of the Company’s board of directors, (B) by a committee of Disinterested Directors designated by a majority vote of the Disinterested Directors, even though less than a quorum of the Company’s board of directors, (C) if there are no such Disinterested Directors or, if such Disinterested Directors so direct, by Independent Counsel in a written opinion to the Company’s board of directors, a copy of which shall be delivered to Indemnitee or (D) if so directed by the Company’s board of directors, by the shareholders of the Company. If it is determined that Indemnitee is entitled to indemnification, payment to Indemnitee shall be made within twenty days after such determination. Indemnitee shall cooperate with the person, persons or entity making the determination with respect to Indemnitee’s entitlement to indemnification, including providing to such person, persons or entity upon reasonable advance request any documentation or information that is not privileged or otherwise protected from disclosure and that is reasonably available to Indemnitee and reasonably necessary to such determination. Any costs or expenses (including attorneys’ fees and disbursements) actually and reasonably incurred by Indemnitee in so cooperating with the person, persons or entity making such determination shall be borne by the Company (irrespective of the determination as to Indemnitee’s entitlement to indemnification), and the Company hereby agrees to indemnify and hold Indemnitee harmless therefrom to the extent permitted by applicable law.  
c.In the event the determination of entitlement to indemnification is to be made by Independent Counsel pursuant to Section 10(b), the Independent Counsel shall be selected as provided in this Section 10(c). If a Change in Control shall not have occurred, the Independent Counsel shall be selected by the Company’s board of directors, and the Company shall give written notice to Indemnitee advising him or her of the identity of the Independent Counsel so selected. If a Change in Control shall have occurred, the Independent Counsel shall be selected by Indemnitee (unless Indemnitee shall request that such selection be made by the Company’s board of directors, in which event the preceding sentence shall apply), and Indemnitee shall give written notice to the Company advising it of the identity of the Independent Counsel so selected. In either event, Indemnitee or the Company, as the case may be, may, within ten days after such written notice of selection shall have been given, deliver to the Company or to Indemnitee, as the case may be, a written objection to such selection; provided, however, that such objection may be asserted only on the ground that the Independent Counsel so selected does not meet the requirements of “Independent Counsel” as defined in Section 1 of this Agreement, and the objection shall 

set forth with particularity the factual basis of such assertion. Absent a proper and timely objection, the person so selected shall act as Independent Counsel. If such written objection is so made and substantiated, the Independent Counsel so selected may not serve as Independent Counsel unless and until such objection is withdrawn or a court has determined that such objection is without merit. If, within 20 days after the submission by Indemnitee of a written request for indemnification pursuant to Section 10(a) hereof, the parties have not agreed upon an Independent Counsel, either the Company or Indemnitee may petition a court of competent jurisdiction for resolution of any objection which shall have been made by the Company or Indemnitee to the other’s selection of Independent Counsel and for the appointment as Independent Counsel of a person selected by the court or by such other person as the court shall designate, and the person with respect to whom all objections are so resolved or the person so appointed shall act as Independent Counsel under Section 10(b) hereof. Upon the due commencement of any judicial proceeding or arbitration pursuant to Section 12(a) of this Agreement, the Independent Counsel shall be discharged and relieved of any further responsibility in such capacity (subject to the applicable standards of professional conduct then prevailing).
d.The Company agrees to pay the reasonable fees and expenses of any Independent Counsel and to fully indemnify such counsel against any and all Expenses, claims, liabilities and damages arising out of or relating to this Agreement or its engagement pursuant hereto.
e.Notwithstanding a final determination by any reviewing party identified in Section 10(b) above that Indemnitee is not entitled to indemnification with respect to a specific Proceeding, Indemnitee shall have the right to apply to the courts of the British Virgin Islands, for the purpose of enforcing Indemnitee’s right to indemnification pursuant to the provisions of this Agreement, the Company’s memorandum and articles of association or BVI Law. 
11.Presumptions and Effect of Certain Proceedings.
a.In making a determination with respect to entitlement to indemnification hereunder, the person, persons or entity making such determination shall, to the fullest extent not prohibited by law, presume that Indemnitee is entitled to indemnification under this Agreement, and the Company shall, to the fullest extent not prohibited by law, have the burden of proof to overcome that presumption. 
b.The termination of any Proceeding or of any claim, issue or matter therein, by judgment, order, settlement or conviction, or upon a plea of nolo contendere or its equivalent, shall not (except as otherwise expressly provided in this Agreement) of itself adversely affect the right of Indemnitee to indemnification or create a presumption that Indemnitee did not act in good faith and in a manner which he or she reasonably believed to be in or not opposed to the best interests of the Company or, with respect to any criminal Proceeding, that Indemnitee had reasonable cause to believe that his or her conduct was unlawful.
c.For purposes of any determination of good faith, Indemnitee shall be deemed to have acted in good faith to the extent Indemnitee’s actions are or were based on (i) the records or books of account of the Enterprise, including financial statements, (ii) information supplied to Indemnitee by the directors or officers of the Enterprise in the course of their duties, (iii) the advice of legal counsel for the Enterprise or its board of directors or counsel selected by any committee of the board of directors or (iv) information or records given or reports made to the Enterprise, its board of directors or any committee of the board of 

directors by an independent certified public accountant, an appraiser, investment banker or other expert selected by the Enterprise or its board of directors or any committee of the board of directors. The provisions of this Section 11(c) shall not be deemed to be exclusive or to limit in any way the other circumstances in which Indemnitee may be deemed or found to have met the applicable standard of conduct set forth in this Agreement. 
d.Neither the knowledge, actions nor failure to act of any other director, officer, manager, fiduciary, agent or employee of the Enterprise shall be imputed to Indemnitee, nor create a presumption against Indemnitee or a defense to an action, for purposes of determining the right to indemnification under this Agreement.
e.If the person, persons or entity empowered or selected under Section 10 of this Agreement to determine whether Indemnitee is entitled to indemnification shall not have made a determination within thirty (30) days after receipt by the Company of the request therefor, the requisite determination of entitlement to indemnification shall, to the fullest extent permitted by law, be deemed to have been made and Indemnitee shall be entitled to such indemnification, absent (i) a misstatement by Indemnitee of a material fact, or an omission of a material fact necessary to make Indemnitee’s statement not materially misleading, in connection with the request for indemnification, or (ii) a final judicial determination that any or all such indemnification is expressly prohibited under applicable law; provided, however, that such 30-day period may be extended for a reasonable time, not to exceed an additional fifteen (15) days, if the person, persons or entity making the determination with respect to entitlement to indemnification in good faith requires such additional time for the obtaining or evaluating of documentation and/or information relating thereto.
12.Remedies of Indemnitee.
a.In the event that (i) a determination is made pursuant to Section 10 of this Agreement that Indemnitee is not entitled to indemnification under this Agreement, (ii) advancement of Expenses, to the fullest extent permitted by applicable law, is not timely made pursuant to Section 8 or 11(e)(d) of this Agreement, (iii) no determination of entitlement to indemnification shall have been made pursuant to Section 10 of this Agreement within 30 days after the receipt by the Company of the request for indemnification or, if later, the final disposition of the Proceeding if such Proceeding was brought under Section 3 of this Agreement and Company is seeking an adjudication that Indemnitee is liable to the Company, (iv) payment of indemnification pursuant to this Agreement is not made (A) within twenty days after a determination has been made that Indemnitee is entitled to indemnification or (B) with respect to indemnification pursuant to Sections 4, 5, 11(e)(d) or the last sentence of Section 10(b) of this Agreement, within 15 days after receipt by the Company of a written request therefor, (v) a contribution payment is not made in a timely manner pursuant to Section 13 of this Agreement, or (vi) the Company or any other person or entity takes or threatens to take any action to declare this Agreement void or unenforceable, or institutes any litigation or other action or proceeding designed to deny, or to recover from, Indemnitee the benefits provided or intended to be provided to Indemnitee hereunder, Indemnitee shall be entitled to an adjudication by a court of competent jurisdiction of his or her entitlement to such indemnification or advancement of Expenses. The Company shall not oppose Indemnitee’s right to seek any such adjudication in accordance with this Agreement.

b.Neither (i) the failure of the Company, its board of directors, any committee or subgroup of the board of directors, Independent Counsel or shareholders to have made a determination that indemnification of Indemnitee is proper in the circumstances because Indemnitee has met the applicable standard of conduct, nor (ii) an actual determination by the Company, its board of directors, any committee or subgroup of the board of directors, Independent Counsel or shareholders that Indemnitee has not met the applicable standard of conduct, shall create a presumption that Indemnitee has or has not met the applicable standard of conduct. In the event that a determination shall have been made pursuant to Section 10 of this Agreement that Indemnitee is not entitled to indemnification, any judicial proceeding commenced pursuant to this Section 11(e) shall be conducted in all respects as a de novo trial, on the merits, and Indemnitee shall not be prejudiced by reason of that adverse determination. In any judicial proceeding commenced pursuant to this Section 11(e), (x) Indemnitee shall be presumed to be entitled to be indemnified, held harmless, and to receive advances of Expenses under this Agreement, (y) the Company shall, to the fullest extent not prohibited by law, have the burden of proving Indemnitee is not entitled to indemnification or advancement of Expenses, as the case may be and (z) the Company may not refer to or introduce into evidence any determination pursuant to Section 10 of this Agreement adverse to Indemnitee for any purpose. If Indemnitee commences a judicial proceeding pursuant to this Section 12, Indemnitee shall not be required to reimburse the Company for any advances pursuant to Section 8 until a final determination is made with respect to Indemnitee’s entitlement to indemnification (as to which all rights of appeal have been exhausted or lapsed).
c.To the fullest extent not prohibited by law, the Company shall be precluded from asserting in any judicial proceeding commenced pursuant to this Section 11(e) that the procedures and presumptions of this Agreement are not valid, binding and enforceable and shall stipulate in any such court that the Company is bound by all the provisions of this Agreement. If a determination shall have been made pursuant to Section 10 of this Agreement that Indemnitee is entitled to indemnification, the Company shall be bound by such determination in any judicial proceeding commenced pursuant to this Section 11(e), absent (i) a misstatement by Indemnitee of a material fact, or an omission of a material fact necessary to make Indemnitee’s statements not materially misleading, in connection with the request for indemnification, or (ii) a prohibition of such indemnification under applicable law. 
d.To the extent not prohibited by law, the Company shall indemnify and hold Indemnitee harmless to the fullest extent permitted by applicable law, against all Expenses that are incurred by Indemnitee in connection with any action (i) to enforce his or her rights under, or to recover damages for breach of, this Agreement or any other indemnification, hold harmless, advancement or contribution agreement or provision of the Company’s memorandum and articles of association or BVI Law now or hereafter in effect; or (ii) for recovery or advances under any insurance policy maintained by any person for the benefit of Indemnitee, regardless of the outcome and whether Indemnitee ultimately is determined to be entitled to such indemnification or hold harmless right, advancement, contribution or insurance recovery, as the case may be (unless such action was brought by Indemnitee in bad faith). If requested by Indemnitee, the Company shall (as soon as reasonably practicable, but in any event no later than 20 days, after receipt by the Company of a written request therefor) advance such Expenses to Indemnitee, subject to the provisions of Section 8.

13.Contribution. To the fullest extent permissible under applicable law, if the indemnification and/or hold harmless rights provided for in this Agreement are unavailable to Indemnitee in whole or in part for any reason whatsoever, the Company, in lieu of indemnifying or holding harmless Indemnitee, shall, by direct payment in the first instance, contribute to the amounts incurred by Indemnitee, whether for Expenses, judgments, fines or amounts paid or to be paid in settlement: (a) in their entirety in connection with any claim or Proceeding relating to an indemnifiable event under this Agreement in which the Company and Indemnitee are held to be jointly liable without requiring Indemnitee to contribute to or offset such payment(s), and the Company hereby waives and relinquishes any right of contribution it may have at any time against Indemnitee, or (b) in such proportion as is deemed fair and reasonable in light of all of the circumstances of such Proceeding in order to reflect (x) the relative benefits received by the Company and Indemnitee as a result of the events and transactions giving rise to such Proceeding; and (y) the relative fault of Indemnitee and the Company (and its other directors, officers, employees and agents) in connection with such events and transactions, in connection with (i) any claim or Proceeding under Section 13(a) solely to the extent full payment of amounts incurred by Indemnitee is not permissible under applicable law, or (ii) any other claim or Proceeding relating to an indemnifiable event under this Agreement.

The Company hereby agrees to fully indemnify and hold harmless Indemnitee from any claims for contribution which may be brought by officers, directors or employees of the Company other than Indemnitee who may be jointly liable with Indemnitee.
14.Non-exclusivity. The rights of indemnification and to receive advancement of Expenses as provided by this Agreement shall not be deemed exclusive of any other rights to which Indemnitee may at any time be entitled under applicable law, the Company’s memorandum and articles of association, any agreement, a vote of shareholders or a resolution of directors, or otherwise. To the extent that a change in BVI Law, whether by statute or judicial decision, permits greater indemnification or advancement of Expenses than would be afforded currently under the Company’s memorandum and articles of association and this Agreement, it is the intent of the parties hereto that Indemnitee shall enjoy by this Agreement the greater benefits so afforded by such change, subject to the restrictions expressly set forth herein or therein. Except as expressly set forth herein, no right or remedy herein conferred is intended to be exclusive of any other right or remedy, and every other right and remedy shall be cumulative and in addition to every other right and remedy given hereunder or now or hereafter existing at law or in equity or otherwise. Except as expressly set forth herein, the assertion or employment of any right or remedy hereunder, or otherwise, shall not prevent the concurrent assertion or employment of any other right or remedy.
15.Primary Responsibility. The Company acknowledges that Indemnitee may have certain rights to indemnification and advancement of expenses provided by third parties (collectively, the “Secondary Indemnitors”). The Company agrees that, as between the Company and the Secondary Indemnitors, the Company is primarily responsible for amounts required to be indemnified or advanced under the Company’s memorandum and articles of association or this Agreement and any obligation of the Secondary Indemnitors to provide indemnification or advancement for the same amounts is secondary to those Company obligations. To the extent not in contravention of any insurance policy or policies 

providing liability or other insurance for the Company or any director, trustee, general partner, managing member, officer, employee, agent or fiduciary of the Company or any other Enterprise, the Company waives any right of contribution or subrogation against the Secondary Indemnitors with respect to the liabilities for which the Company is primarily responsible under this Section 15. In the event of any payment by the Secondary Indemnitors of amounts otherwise required to be indemnified or advanced by the Company under the Company’s memorandum and articles of association or this Agreement, the Secondary Indemnitors shall be subrogated to the extent of such payment to all of the rights of recovery of Indemnitee for indemnification or advancement of expenses under the Company’s memorandum and articles of association or this Agreement or, to the extent such subrogation is unavailable and contribution is found to be the applicable remedy, shall have a right of contribution with respect to the amounts paid; provided, however, that the foregoing sentence will be deemed void if and to the extent that it would violate any applicable insurance policy. The Secondary Indemnitors are express third-party beneficiaries of the terms of this Section 15. Notwithstanding any other provision of this Agreement to the contrary, (i) Indemnitee shall have no obligation to reduce, offset, allocate, pursue or apportion any indemnification, hold harmless, advancement, contribution or insurance coverage among multiple parties possessing such duties to Indemnitee prior to the Company’s satisfaction and performance of all its obligations under this Agreement, and (ii) the Company shall perform fully its obligations under this Agreement without regard to whether Indemnitee holds, may pursue or has pursued any indemnification, advancement, hold harmless, contribution or insurance coverage rights against any person or entity other than the Company.
16.No Duplication of Payments. Subject to any subrogation rights set forth in Section 15, the Company shall not be liable under this Agreement to make any payment of amounts otherwise indemnifiable hereunder (or for which advancement is provided hereunder) if and to the extent that Indemnitee has otherwise actually received payment for such amounts under any insurance policy, contract, agreement or otherwise.
17.Insurance. The Company shall use commercially reasonable efforts to obtain and maintain in effect during the entire period for which the Company is obligated to indemnify the Indemnitee under this Agreement, one or more policies of insurance with reputable insurance companies to provide the officers/directors of the Company with coverage for losses from wrongful acts and omissions and to ensure the Company’s performance of its indemnification obligations under this Agreement. To the extent that the Company maintains an insurance policy or policies providing liability insurance for directors, trustees, general partners, managing members, officers, employees, agents or fiduciaries of the Company or any other Enterprise, Indemnitee shall be covered by such policy or policies to the same extent, and with the same rights and benefits, as the most favorably-insured directors and officers under such policy or policies. The purchase, establishment, and maintenance of an insurance policy shall not in any way limit or affect the rights and obligations of the Company or of Indemnitee under this Agreement except as expressly provided herein, and the execution and delivery of this Agreement by the Company and Indemnitee shall not in any way limit or affect the rights and obligations of the Company under any such insurance policy. If, at the time the Company receives notice from any source of a Proceeding as to which Indemnitee is a party or a participant (as a witness, deponent or otherwise), the Company has director and officer liability insurance in effect, the Company shall give prompt notice of such Proceeding to the insurers in accordance with the procedures set forth in the respective policies. The Company shall 

thereafter use commercially reasonable efforts to cause such insurers to pay, on behalf of Indemnitee, all amounts payable as a result of such Proceeding in accordance with the terms of such policies
18.Subrogation. In the event of any payment under this Agreement, the Company shall, to the fullest extent permitted by law, be subrogated to the extent of such payment to all of the rights of recovery of Indemnitee, who shall execute all papers required and take all action necessary to secure such rights, including execution of such documents as are necessary to enable the Company to bring suit to enforce such rights. No such payment by the Company shall be deemed to relieve any insurer of its obligations.
19.Services to the Company. Indemnitee agrees to serve as a director or officer of the Company or, at the request of the Company, as a director, trustee, general partner, managing member, officer, employee, agent or fiduciary of another Enterprise, for so long as Indemnitee is duly elected or appointed or until Indemnitee tenders his or her resignation or is removed from such position. Indemnitee may at any time and for any reason resign from such position (subject to any other contractual obligation or any obligation imposed by operation of law). This Agreement shall not be deemed an employment contract between the Company (or any of its Subsidiaries or any Enterprise) and Indemnitee. Indemnitee specifically acknowledges that any employment with the Company (or any of its Subsidiaries or any Enterprise) is at will, and Indemnitee may be discharged at any time for any reason, with or without cause, with or without notice, except as may be otherwise expressly provided in any executed, written employment contract between Indemnitee and the Company (or any of its Subsidiaries or any Enterprise), any existing formal severance policies adopted by the Company’s board of directors or, with respect to service as a director or officer of the Company, the Company’s memorandum and articles of association or BVI Law. No such document shall be subject to any oral modification thereof. 
20.Duration. The indemnification, contribution and advancement of Expenses provided by, or granted pursuant to this Agreement shall continue during the period Indemnitee is an officer and/or a director of the Company or is or was serving at the request of the Company and shall continue thereafter so long as Indemnitee shall be subject to any Proceeding by reason of her former or current capacity at the Company or any other Enterprise at the Company’s request, whether or not she is acting or serving in any such capacity at the time any Expense is incurred for which indemnification can be provided under this Agreement..
21.Successors. This Agreement shall be binding upon the Company and its successors and assigns, including any direct or indirect successor, by purchase, merger, consolidation or otherwise, to all or substantially all of the business or assets of the Company, and shall inure to the benefit of Indemnitee and Indemnitee’s heirs, executors and administrators. The Company shall require and cause any successor (whether direct or indirect by purchase, merger, consolidation or otherwise) to all or substantially all of the business or assets of the Company, by written agreement, expressly to assume and agree to perform this Agreement in the same manner and to the same extent that the Company would be required to perform if no such succession had taken place.
22.Severability. Nothing in this Agreement is intended to require or shall be construed as requiring the Company to do or fail to do any act in violation of applicable law. The Company’s inability, pursuant to court order or other applicable law, to perform its obligations under this Agreement shall not constitute a breach of this Agreement. If any provision or provisions of this Agreement shall be held to be invalid, 

illegal or unenforceable for any reason whatsoever: (i) the validity, legality and enforceability of the remaining provisions of this Agreement (including without limitation, each portion of any section of this Agreement containing any such provision held to be invalid, illegal or unenforceable, that is not itself invalid, illegal or unenforceable) shall not in any way be affected or impaired thereby and shall remain enforceable to the fullest extent permitted by law; (ii) such provision or provisions shall be deemed reformed to the extent necessary to conform to applicable law and to give the maximum effect to the intent of the parties hereto; and (iii) to the fullest extent possible, the provisions of this Agreement (including, without limitation, each portion of any section of this Agreement containing any such provision held to be invalid, illegal or unenforceable, that is not itself invalid, illegal or unenforceable) shall be construed so as to give effect to the intent manifested thereby.
23.Enforcement. The Company expressly confirms and agrees that it has entered into this Agreement and assumed the obligations imposed on it hereby in order to induce Indemnitee to serve as a director or officer of the Company, and the Company acknowledges that Indemnitee is relying upon this Agreement in serving as a director or officer of the Company.  If for the validation of any of the provisions in this Agreement any act, resolution, approval or other procedure is required, to the fullest extent permitted by law, the Company undertakes to cause such act, resolution, approval or other procedure to be affected or adopted in a manner that will enable the Company to fulfill its obligations under this Agreement.
24.Period of Limitations. No legal action shall be brought and no cause of action shall be asserted by or in the right of the Company against Indemnitee, Indemnitee’s spouse, heirs, executors or personal or legal representatives after the expiration of two years from the date of accrual of such cause of action, and any claim or cause of action of the Company shall be extinguished and deemed released unless asserted by the timely filing of a legal action within such two-year period; provided, however, that if any shorter period of limitations is otherwise applicable to any such cause of action such shorter period shall govern. The period of limitations set forth in this Section 24 shall no longer be applicable in the case of fraud or willful misconduct.
25.Entire Agreement. This Agreement constitutes the entire agreement between the parties hereto with respect to the subject matter hereof and supersedes all prior agreements and understandings, oral, written and implied, between the parties hereto with respect to the subject matter hereof; provided, however, that this Agreement is a supplement to and in furtherance of the Company’s obligations to Indemnitee as provided by its memorandum and articles of association, and by applicable law. 
26.Modification and Waiver. No supplement, modification or amendment to this Agreement shall be binding unless executed in writing by the parties hereto. No amendment, alteration or repeal of this Agreement or the Company’s memorandum and articles of association shall adversely affect any right of Indemnitee under this Agreement or the Company’s memorandum and articles of association in respect of any Proceeding (regardless of when such Proceeding is first threatened, commenced or completed) or claim, issue or matter therein arising out of, or related to, any action taken or omitted by such Indemnitee in his or her Corporate Status prior to such amendment, alteration or repeal. To the extent that a change in applicable law, whether by statute or judicial decision, permits greater indemnification rights or advancement of Expenses than would be afforded currently under the Company’s memorandum and articles of association or 

this Agreement, then this Agreement (without any further action by the parties hereto) shall automatically be deemed to be amended to require that the Company indemnifies the Indemnitee to the fullest extent permitted by law. No waiver of any of the provisions of this Agreement shall constitute or be deemed a waiver of any other provision of this Agreement nor shall any waiver constitute a continuing waiver. 
27.Notices. All notices and other communications required or permitted hereunder shall be in writing and shall be mailed by registered or certified mail, postage prepaid, sent by facsimile or electronic mail or otherwise delivered by hand, messenger or courier service addressed:
a.if to Indemnitee, to Indemnitee’s address, facsimile number or electronic mail address as shown on the signature page of this Agreement or in the Company’s records, as may be updated in accordance with the provisions hereof; or
b.if to the Company, to the attention of the Chief Executive Officer or Chief Financial Officer of the Company at Establishment Labs Holdings Inc., Coyol Free Zone, Building B25, Alajuela, 20113, Costa Rica, or at such other current address as the Company shall have furnished to Indemnitee, with an electronic copy (which shall not constitute notice) to [LEGAL NOTICE EMAIL ADDRESS(ES)] and the email address of the Company’s then-current General Counsel. 
Each such notice or other communication shall for all purposes of this Agreement be treated as effective or having been given (i) if delivered by hand, messenger or courier service, when delivered (or if sent via a nationally-recognized overnight courier service, freight prepaid, specifying next-business-day delivery, one business day after deposit with the courier), or (ii) if sent via mail, at the earlier of its receipt or five days after the same has been deposited in a regularly-maintained receptacle for the deposit of the United States mail, addressed and mailed as aforesaid, or (iii) if sent via facsimile, upon confirmation of facsimile transfer or, if sent via electronic mail, upon confirmation of delivery when directed to the relevant electronic mail address, if sent during normal business hours of the recipient, or if not sent during normal business hours of the recipient, then on the recipient’s next business day.
28.Applicable Law and Consent to Jurisdiction. This Agreement and the legal relations among the parties shall be governed by, and construed and enforced in accordance with, the laws of the British Virgin Islands, without regard to its conflict of laws rules. The Company and Indemnitee hereby irrevocably and unconditionally (i) agree that any action or proceeding arising out of or in connection with this Agreement shall be brought only in the courts of the British Virgin Islands, (ii) consent to submit to the exclusive jurisdiction of the courts of the British Virgin Islands for purposes of any action or proceeding arising out of or in connection with this Agreement, (iii) appoint, to the extent such party is not otherwise subject to service of process in the British Virgin Islands, Conyers Trust Company (BVI) Limited, Incorporation Services, Ltd. as its agent for acceptance of legal process in connection with any such action or proceeding against such party, (iv) waive any objection to the laying of venue of any such action or proceeding in the courts of the British Virgin Islands.
29.Counterparts. This Agreement may be executed in one or more counterparts, each of which shall for all purposes be deemed to be an original but all of which together shall constitute one and the same Agreement. This Agreement may also be executed and delivered by facsimile signature and in counterparts, each of which shall for all purposes be deemed to be an original but all of which together 

shall constitute one and the same Agreement. Only one such counterpart signed by the party against whom enforceability is sought needs to be produced to evidence the existence of this Agreement.
30.Captions. The headings of the paragraphs of this Agreement are inserted for convenience only and shall not be deemed to constitute part of this Agreement or to affect the construction thereof.

(signature page follows)

The parties are signing this Indemnification Agreement as of the date stated in the introductory sentence.

									
			ESTABLISHMENT LABS HOLDINGS INC.
			
			(Signature)

			
			(Print name)

			
			(Title)

			
			 [NAME]
			
			(Signature)

			[On file with Company] 

			(Street address)

			[On file with Company] 

			(City, State and ZIP)

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