Document:

exhibit1024.htm

Exhibit 10.24

 

PROMISSORY NOTE AGREEMENT

AGREEMENT made this 1st day of February, 2013 by and among H.D. Smith Wholesale Drug Co., having its principal place of business at 3063 Fiat Ave., Springfield, IL, a corporation formed under the laws of the State of Delaware, (hereinafter "Lender" or "Supplier"), and Assured Pharmacy, Inc., having an office located at 2595 Dallas Parkway, Suite 206, Hall Office Park, Frisco, TX 75034, a corporation formed under the laws of the State of Nevada (hereinafter "Borrower" or "Purchaser"),

 

W I T N E S S E T H:

 

Whereas, on and between January 1, 2010 and January 16, 2013, Purchaser purchased goods in the agreed upon price and reasonable value of Three Million Eight Hundred Twenty Eight Thousand Five Hundred Twenty Six Dollars & 64/100 ($3,828,526.64), which remains unpaid,

 

Whereas, the Supplier has agreed to modify its payment terms to permit Borrower  to make payments in a manner that is flexible, but conditioned upon the terms, covenants and conditions contained herein, but Purchaser hereby agrees that this modification in no way operates as a waiver or estoppel of enforcement of Supplier's payment terms at any point in the future,

 

Now, therefore, in consideration of their mutual covenants, terms and conditions more fully set forth below, and in consideration of the Purchaser's execution and delivery of various incidental agreements, including, but not limited to, cross-corporate guaranties of the related corporations, and the Security Agreement, which terms and conditions of these other said Agreements are incorporated herein by express reference, and in consideration of the Purchaser's agreement to make lump-sum payments and returns satisfying and paying-off the related corporations' indebtedness to Supplier, parties hereby agree as follows:

 

ABSOLUTE AND UNCONDITIONAL PROMISE TO PAY.   FOR  VALUABLE CONSIDERATION RECEIVED, BORROWER HEREBY ACKNOWLEDGES AND ADMITS, without reservation or condition that the Principal Amount of $3,828,526.64 plus interest, is owed to Lender inclusive of all payments, returns, credits and other offsets through today's date, for a prior overdue balance admittedly owed to Lender, and that said shipments conformed in all respects to the respective orders placed by the Borrower), and to induce Lender into forbearance from instituting immediate suit, and for other valuable consideration, receipt of which is hereby acknowledged, and Borrower hereby acknowledges Lender is relying upon the instant Absolute and Unconditional Promissory Note in granting this accommodation by extending its payment terms; Borrower hereby absolutely and unconditionally promises to pay to the order of H.D. Smith Wholesale Drug Co., a Delaware Corporation, at the address designated for Lender above, the sum of $3,828,526.64 subject to the following terms.  Borrower absolutely, unconditionally and irrevocably waives any and all right to assert any defense, set-off, counterclaim or cross-claim of any nature whatsoever with respect to this instrument or the obligations of the Makers under this instrument or the obligations of any other person or party (including, without limitation, Borrower) relating to this instrument or the obligations of the Borrower under the instrument or otherwise with respect to the Loan in any action or proceeding brought by the Lender hereof to collect the Debt or any portion thereof, or to enforce, the obligations of the Borrower under this instrument.

 

 1.        TERM.    The term of this agreement shall be for a period of 12 months ending on February 1, 2014 (hereinafter "Maturity Date").

 

2.         INTEREST RATE.  Interest will be calculated on the remaining outstanding principal balance at an annual percentage rate of 6.25%, payable monthly.

 

 

 

 

 

 

  

Page 1 of 5

  

 

 

 

3.         PAYMENTS.  Commencing on  March  1,  2013, Borrower shall  make four  (4)  successive  monthly payments, principal and interest, of$27,000.00  each. Commencing July 1, 2013, Borrower shall make four (4) successive monthly payments, principal and interest, of $37,000.00 each. Commencing on November 1, 2013, Borrower shall make three (3) successive monthly payment, principal and interest, of $42,000.00 each. On February 1, 2014, Borrower shall make a final payment, principal and interest, of $3,681,709.70. Payments shall be credited first to late fees, if any, then to interest, and then to principal.

 

To the extent that any rebate is due Borrower by the Lender, arising out of Borrower's purchases of goods and services from Lender, such rebate, at Lender's sole discretion, may be, by way of offset, applied against Borrower's monthly payment obligation hereunder. For example, if Borrower's current payment obligation is $37,000.00, and Borrower is entitled to a $12,000.00 rebate, Lender may apply such rebate to reduce Borrower's Note payment to $25,000.00.

 

Notwithstanding the payment schedule described in this Section 3, if Borrower issues, sells, transfers or agrees to issue, sell or transfer any future equity interest in borrower or the Borrower enters into any future transaction which results in any right to convert to an equity interest in borrower, 25% of the amount paid to Borrower in any future transaction will be paid to Lender who will apply that amount to the amount due hereunder. Borrower will make payment to Lender as soon as amounts are received by Borrower until the 25% limit is reached and all amounts received by borrower will first be paid to Lender before used for any other purpose.  Lender will apply such payments to the final payment due hereunder and if that amount is fully paid then to the last remaining payments due hereunder, in order, until each is satisfied.

 

In the event any payment shall not be received by Lender on or before its due date, a late fee equal to five percent (5%) of such delinquent payment shall immediately be due and payable by Borrower.

 

4.         DEPOSITORY ACCOUNT.    As an inducement and further consideration for Lender to extend the credit evidenced by this Note, Borrower will make a cash deposit of Five Hundred Thousand Dollars ($500,000.00) ("Initial Balance") into a separate account to be held by the Lender ("Depository Account"). The Depository Account will be treated as a prepaid account for the funding of pending current orders, so that all such orders shall be released without delay or hold.

 

5.         ACCELERATION. Upon the Maturity Date or upon termination for any other reason set forth herein, the full balance consisting of principal and accrued interest shall become accelerated and due immediately.

 

6.         SECURITY INTEREST.   Borrower hereby agrees to execute and deliver a Security Agreement in the form drafted by the Lender concurrent with the execution and delivery of this Agreement.

 

7.         DEFAULT.   Lender may terminate this Promissory Note, accelerate and declare the entire balance then outstanding under this Agreement to be immediately due and payable, suspend or cease any future credit and/or shipments, commence suit to recover all sums due, commence a relevant action and charge the default interest and reasonable costs of collection, including, but not limited to, the reasonable legal fees incurred by Lender in the event that any event of default shall occur. Events of default are as follows: (a) Any fraud or  material misrepresentation in connection with any  information provided in the credit application, and/or any other Agreement incorporated herein by express reference, by Borrower and/or any cross-corporate guarantor; (b) Borrower does not meet the payment terms of this Agreement and/or the payment terms of any trade debt incidental to this Agreement; (c) Any Cross-corporate guarantor does not meet the payment terms of any Agreement it has executed and delivered to Lender and/or fails to meet the payment terms of any trade debt balance owed to Lender; (d) Borrower or any cross-corporate guarantor fails to satisfy any term, condition and/or covenant of this Agreement or any Agreement incorporated herein by express reference; (d) any action or conduct  adversely affects the value of the collateral, the collateral, or the Lender's rights in the collateral; (e) any Bulk transfer outside the ordinary course of business; (f) failure of Maker to meet minimum purchases of $500,000 per month, in any single month during term of this Note; (g) any breach or violation of the  purchase agreement by and  between Supplier and Purchaser; and/or (h) filing by or against Borrower or any Guarantor of a petition in bankruptcy or for a receiver for Borrower or Guarantor or any property thereof.

 

 

 

 

  

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8.         BULK TRANSFER PROHIBITION.    Any transfer of the Borrower's Assets in bulk outside the ordinary course of business shall be a term of default under this Agreement.  In the event that Borrower shall intend to make a transfer in bulk of any collateral, it shall give the Lender twenty (20) days advance notice of such transfer, including all transferees, the assets being transferred, the consideration being paid, and the date and place of the closing.  All sums due to the Lender under this Agreement shall become accelerated and shall become immediately due upon any bulk transfer. Borrower hereby agrees not to accept any proceeds of any sale unless certified funds  have been tendered directly by the transferee to the Lender to satisfy all debts then due or overdue and owing.

 

9.         INSURANCE. Borrower hereby agrees to purchase insurance against loss or damage to the collateral listed by the Security Agreement in such amounts and against all such risks as the Lender may reasonably require.  The Lender must be listed as a payee and must be listed as a recipient to receive notice of any cancellation of the policy.

 

10.       NO ASSIGNMENT BY DEBTOR.   Lender does not consent to any assignment by Borrower.  For purposes of this Agreement, any sale or disposition or transfer of  stock of  Purchaser shall  be deemed an assignment.

 

11.       SEVERABILITY.  Should any provision of this Agreement be found to be void, invalid or unenforceable by a court or by an arbitrator of competent jurisdiction, that finding shall affect the provisions found to be void, invalid or unenforceable and shall not affect the remaining provisions of this Agreement not addressed by such court or arbitrator.

 

12.       NOTICES.

 

A.   Presentment for payment, demand, notice of dishonor, protest, notice protest and all other demands and notices in connection with the delivery, performance and enforcement of this Note are hereby waived.

 

B.    Any notices required by this Agreement shall be deemed to be delivered when it has been (a) deposited in any United States Postal box if postage is prepaid, and the notice properly addressed to the intended recipient, (b) received by telecopy, (c) received through the internet, and /or (d) when personally delivered. If there has been any change of address of the Borrower without prior notification to the Lender, it shall be no defense or objection that the notice was not "properly addressed".

 

13.        HEADINGS.  Section headings used by this Agreement are for convenience only.  They are not a part of this Agreement and shall not be used in construing it.

 

14.        INTEGRATION AND MODIFICATIONS.

 

A.This Agreement is the entire agreement between the parties concerning the subject matter, except for those documents and agreements previously incorporated herein by express reference.

 

 

 

 

  

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B.   Any modifications to this Agreement must be made in writing and signed by the party adversely affected or to be charged with enforcement.

 

15.       NON-WAIVER.  Waiver or acquiescence in any default by the Borrower, or failure of the Lender to insist upon strict performance by the Borrower of any warranties, covenants, terms or agreements in this Agreement, shall not constitute a waiver or an estoppel of any subsequent or other default or failure, and shall further not estop Lender from enforcing that default in any subsequent proceeding or action.

 

16.       FURTHER ASSURANCES.   Borrower  hereby  agrees to execute any further  documents,  and to take any further actions, reasonably requested by the Lender to effectuate the rights granted to Lender herein.

 

17.       GOVERNING LAW. This Agreement shall be governed by and construed  in accordance  with the federal Jaws of the United States of America and internal laws of the State of California applicable to contracts made and to be performed  in such state (without regard to the principle  of conflicts of law applicable under California law).  It is the intent of the parties that to the fullest extent permitted by Jaw, the Jaws of the State of California shall govern this Agreement.   To the  maximum  extent  permitted  by Jaw, Debtor hereby agrees that all actions or proceedings arising in connection  with this agreement  or any course of conduct, course of dealing, statements (whether written or oral) or actions of Secured Party or Debtor in respect thereof (whether  sounding  in tort or contract or otherwise)  be tried and determined exclusively  in the Superior Court of the State of California, Los Angeles  County, or the United States District Court for the Central District of California.  To the maximum extent permitted by law, Debtor hereby  expressly  waives  any  rights it may have to assert the doctrine  in any intrastate  or interstate proceeding of Forum Non Conveniens  or to object to venue to the extent any proceeding  is brought in accordance with the foregoing Section.  DEBTOR AGREES THAT THE SOLE AND EXCLUSIVE VENUE FOR ANY PROCEEDING INITIATED BY DEBTOR  SHALL BE THE SUPERIOR  COURT  OF THE STATE  OF CALIFORNIA,  IN  THE  COUNTY  OF  LOS  ANGELES  OR  THE  UNITED  STATES  DISTRICT COURT FOR THE CENTRAL DISTRICT OF CALIFORNIA.  To the maximum extent permitted by Jaw, Debtor hereby expressly and irrevocably submits to the personal jurisdiction of the courts of the State of California and of the United States District Court for the Central District of California for the purpose of any and all litigation arising under this agreement or any other document, and irrevocably agrees to be bound by any judgment rendered thereby in connection with such litigation.  Debtor further irrevocably consents to the service of process of the complaint and summons in any such litigation by certified or registered mail, postage prepaid, at the address of Debtor provided herein.   Debtor hereby represents  that  it  has been  represented  by  competent  counsel  of  its  choice  in  the  negotiation  and execution of this Agreement and all other documents associated with the contemplated transaction; that it has read and fully understood  the terms hereof; that Debtor and its counsel  have been afforded  an opportunity to review, negotiate and modify the terms of each document, and that it intends to be bound hereby.  In  accordance  with  the  foregoing,  the  general  rule  of  construction   to  the  effect  that  any ambiguities in a contract are to be resolved against the party drafting the contract shall not be employed in the construction  and interpretation  of this Agreement  or any other  document  between  the parties. Notwithstanding the foregoing, H. D. Smith may, at its option, commence a cause of action in a state or federal court located outside of California.

 

 

 

 

[SIGNATURES ON FOLLOWING PAGE]

 

 

 

 

 

  

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The parties have signed this Agreement as of the day and year first above written at Carson, California. 

 

Borrower 

 

Assured Pharmacy, Inc.,

A Nevada Corporation

 

 

 

/s/     Robert DelVecchio                                                         

By:   Robert DelVecchio, 

         Chief Executive Officer

 

Lender

 

H.D. Smith Wholesale Drug Co.,

A Delaware Corporation

 

/s/   James Christopher Smith                                                 

By:  James Christopher Smith, 

        President

 

 

 

 

 

  

Page 5 of 5exhibit1025.htm

Exhibit 10.25

 

 

 

FORM OF SUBSCRIPTION AGREEMENT FOR COMMON STOCK

CONFIDENTIAL

Assured Pharmacy, Inc.

$2,000,000 of Units of Securities

consisting of

Shares of Common Stock and Warrants

__________________

SUBSCRIPTION

BOOKLET

__________________

TriPoint Global Equities, LLC

Januray 2013

This Subscription Booklet relates to the Offering (the “Offering”) of units of securities (the “Units”) of Assured Pharmacy, Inc., a Nevada corporation (the “Company”). The company is offerring a total of up to 80 Units at an offering price of $25,000 per Unit, for a total Offering amount of up to $2,000,000 (the “Maximum Offering”). Each full $25,000 Unit shall consist of (a) 38,462 shares of our common stock, $0.001 par value per share (the “Common Stock”), with each share of Common Stock valued at $0.65 (the “Per Share Value”), and (b) 38,462 three year warrants (the “Warrants”) entitling the holder to purchase additional shares of Common Stock at an initial exercise price of $0.90 per share (the “Warrant Exercise Price”); which Warrant Exercise Price is subject to certain anti-dilution adjustments. Units in the Offering are only available to Accredited Investors as defined in Rule 501 of Regulation promulgated under the U.S. Securities Act of 1933, as amended (the “Securities Act”).

 

 

 

 

  

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INSTRUCTIONS FOR COMPLETION OF SUBSCRIPTION BOOKLET

This subscription booklet contains your Subscription Agreement and other documents that, if you wish to invest in Units, must be executed and returned to Mark Elenowitz at TriPoint Global Equities, LLC via mail: 17 State Street, Suite 2000, New York, NY 10004; Fax: +1 212 202 6380; or email: mark@tripointglobalequities.com.  TriPoint Global Equities, LLC is acting as Placement Agent. You should consult with an attorney, accountant, investment adviser or other adviser regarding an investment in the Company and its suitability for you.  All subscription documents must be completed correctly and thoroughly or they will not be accepted.  If you wish to invest, please complete, sign and return the documents included herein.

Copies of the following documents must be delivered to the Placement Agent:

TriPoint Global Equities, LLC

17 State Street

Suite 2000

New York, NY 10004

Attention: Mark Elenowitz

Fax No.: 212-202-6380

Email: mark@tripointglobalequities.com or ltaubman@htwlaw.com (counsel to the Placement Agent)

	
(i)  

	
Executed signature page to the Securities Purchase Agreement;

	
(ii)  

	
Completed Subscription Booklet;

	
(iii)  

	
Executed signature page to the Subscription Agreement;

	
(iv)  

	
Executed signature page to the Registration Rights Agreement; and

	
(v)  

	
A clear copy of subscriber’s passport or valid form of government issued identification

The purchase price per Unit is exclusive of any costs incurred by an investor for legal, tax accounting or financial advice, including fees paid to his, her or its purchaser representative, if any.

The Securities Purchase Agreement will be irrevocable by the prospective investor and, unless the subscription is rejected or the Offering is withdrawn, the subscriber will become an investor in this Offering.  We or the Placement Agent may reject subscriptions for failure to conform to the requirements of the Offering, insufficient documentation, oversubscription of the Offering or any such other reason, whatsoever, as we and the Placement Agent, in our sole discretion, may determine.

 

 

 

  

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Assured Pharmacy, Inc.

Wire and Subscription Procedures

The minimum investment that can be made by any subscriber is $25,000; however, an investment of less than $25,000 may be accepted, at the sole discretion of us and the Placement Agent. Any prospective investor who decides to purchase Units should deliver the following items:

  1.           A check or certified funds payable to the order of Wilmington Trust, N.A., as escrow agent for Assured Pharmacy, Inc.” in an amount equal to the total subscription price, should be delivered to

Wilmington Trust Company

Capital Markets and Agency Division

Institutional Custody and Escrow Services

1100 N. Market Street

Wilmington, DE 19890

Phone:  302.636.6439

Attn: Patrick J. Donahue

or

2.          A wire transfer of immediately available funds to the following account maintained at Wilmington Trust, N.A.

 

Wilmington Trust Company

ABA #: 031100092

A/C # 100590-000

A/C Nm:  Assured Pharmacy, Inc.

Attn: Patrick J. Donahue

 

 

 

  

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SECTION I

IMPORTANT NOTICES AND CERTIFICATIONS

Notices

	
·  

	
Your Subscription Agreement is comprised of Section I through V of this Subscription Booklet and your signature page thereto is included as Section V of this Subscription Booklet.

	
·  

	
You as an individual or you on behalf of the subscribing entity are being asked to complete this Subscription Agreement so a determination can be made as to whether or not you (it) are qualified to purchase securities under applicable federal and state securities laws.

	
·  

	
Your answers to the questions contained herein must be true and correct in all respects, and a false representation by you may constitute a violation of law for which a claim for damages may be made against you.

	
·  

	
Your answers will be kept strictly confidential; however, by signing this Subscription Agreement, you will be authorizing the Company to present a completed copy of this Subscription Agreement (and any completed questionnaires and related information submitted by you in connection therewith) to such parties as they may deem appropriate in order to make certain that the offer and sale of the Units will not result in a violation of the Securities Act or of the securities laws of any state or of any other jurisdiction.

	
·  

	
This Subscription Agreement does not constitute an offer to sell or a solicitation of an offer to buy Units or any other security.

	
·  

	
All questions must be answered. If the appropriate answer is "None" or "Not Applicable," please state so. Please print or type your answers to all questions and attach additional sheets if necessary to complete your answers to any item. Please initial any correction.

INDIVIDUAL SUBSCRIBERS:

	
·  

	
If the Units subscribed for are to be owned by more than one person, you and the other co-subscriber must each complete a separate Subscription Agreement (except if the co-subscriber is your spouse) and sign the Signature Page to this Subscription Agreement and the appropriate Signature Page to the Securities Purchase Agreement included as Section X. If your spouse is a co-subscriber, you must indicate his or her name and social security number.

Certifications

	
·  

	
I understand that investment in the Units is an illiquid investment. In particular, I recognize that: (i) I must bear the economic risk of investment in the Units for an indefinite period of time, since the Units have not been registered under the Securities Act and therefore cannot be sold unless either they are subsequently registered under the Securities Act or an exemption from such registration is available and a favorable opinion of counsel for the Company to that effect is obtained (if requested by the Company); and (ii) no established market will exist and it is possible that no public market for the Units, or any part thereof or any security underlying any part thereof, will develop. I consent to the affixing by the Company of such legends on certificates representing the Units (or any part thereof) as any applicable federal or state securities law or any securities law of any other applicable jurisdiction may require from time to time.

 

	
·  

	
I represent and warrant to the Company that: (i) The financial information provided in this Subscription Agreement is complete, true and correct in all material respects; (ii) I and my Investment Managers, if any, have carefully reviewed and understand the risks of, and other considerations relating to, a purchase of Units; (iii) I and my Investment Managers, if any, have been afforded the opportunity to obtain any information necessary to verify the accuracy of any representations or information set forth in the Offering Memorandum dated January 29th, 2013 (the “Offering Memorandum”) and any periodic reports or other public filings of the Company (the “Commission Documents”) and have had all inquiries to the Company answered, and have been furnished all requested materials, relating to the Company and the offering and sale of the Units and anything set forth in the Offering Memorandum or the Commission Documents; (iv) neither I nor my Investment Managers, if any, have been furnished any offering literature by the Company or any of its affiliates, associates or agents other than the Offering Memorandum, the Securities Purchase Agreement, and the agreements referenced therein; (v) I and my Investment Managers, if any, have excellent investment knowledge; and (vi) I am acquiring the Units for which I am subscribing for my own account, as principal, for investment and not with a view to the resale or distribution of all or any part of the Units.

 

 

 

 

 

  

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·  

	
I represent that my investment objective is speculative in that I seek the maximum total return through an investment in a broad spectrum of securities, which involves a higher degree of risk than other investment styles and therefore my risk exposure is also speculative.

	
·  

	
I understand that the purchase price per Unit is exclusive of any costs incurred by me for legal, tax, accounting or financial advice, including fees paid to my purchaser representative, if any.

	
·  

	
The undersigned, if a corporation, partnership, trust or other form of business entity, (i) is authorized and otherwise duly qualified to purchase and hold the Units, (ii) has obtained such additional tax and other advice that it has deemed necessary, (iii) has its principal place of business at its residence address set forth in this Subscription Agreement, and (iv) has not been formed for the specific purpose of acquiring the Units (although this may not necessarily disqualify the subscriber as a purchaser). The persons executing the Subscription Agreement, as well as all other Agreements related to the Offering, represent that they are duly authorized to execute all such Agreements on behalf of the entity. (If the undersigned is one of the aforementioned entities, it agrees to supply any additional written information that may be required.)

	
·  

	
All of the information which I have furnished to the Company and which is set forth in the Subscription Agreement is correct and complete in all material respects as of the date of the Subscription Agreement. If any material change in this information should occur prior to my subscription being accepted, I will immediately furnish the revised or corrected information. I further agree to be bound by all of the terms and conditions of the Offering described in the Offering Memorandum and the Securities Purchase Agreement and the other documents and agreements related thereto. I am the only person with a direct or indirect interest in the Units subscribed for by this Subscription Agreement. I agree to indemnify and hold harmless the Company and its officers, directors and affiliates from and against all damages, losses, costs and expenses (including reasonable attorneys' fees) that they may incur by reason of the failure of the undersigned to fulfill any of the terms or conditions of this Subscription Agreement or by reason of any breach of the representations and warranties made by the undersigned herein or in any Agreement provided by the undersigned to the Company. This subscription is not transferable or assignable by me without the written consent of the Company. If more than one person is executing this Agreement, the obligations of each shall be joint and several and the representations and warranties contained in this Subscription Agreement shall be deemed to be made by, and be binding upon, each of these persons and his or her heirs, executors, administrators, successors and assigns. This subscription, upon acceptance by the Company, shall be binding upon my heirs, executors, administrators, successors and assigns. This Subscription Agreement shall be construed in accordance with and governed in all respects by the laws of the State of New York.

 

	
·  

	
Under penalties of perjury, I certify that (1) my taxpayer identification number shown in this Subscription Agreement is correct and (2) I am not subject to backup withholding because (a) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest and dividends or (b) the Internal Revenue Service has notified me that I am no longer subject to backup withholding. (If you have been notified that you are subject to backup withholding and the Internal Revenue Service has not advised you that backup withholding has been terminated, strike out item (2) in the sentence directly above.)

	
·  

	
The acceptance of my application together with the appropriate remittance will not breach any applicable money laundering rules and regulations and I undertake to provide verification of my identity reasonably satisfactory (on a confidential basis) to the Company promptly on request. I acknowledge that due to money laundering requirements operating within their respective jurisdictions, the Company may require further identification of me/us before applications can be processed. The Company shall be held harmless and indemnified by me against any loss arising from the failure to process this application if such information as has been reasonably required from me has not been provided by me.

	
·  

	
I understand that the Subscription Agreement and the Securities Purchase Agreement relating to the Offering will be irrevocable, and unless the subscription is rejected or withdrawn, I will become an investor in this Offering.  I understand that the Company or the Placement Agent may reject subscriptions for failure to conform to the requirements of the Offering, insufficient documentation, oversubscription of the Offering, or any other reason whatsoever, as the Company and the Placement Agent, in their sole discretion, may determine.

 

 

 

 

 

  

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SECTION II

SUBSCRIBER REGISTRATION

1. Type of Account (Please check one):

Individual Account                                           ______

Joint Account                                                    ______

If no box below is checked, we will issue the securities as JTWROS

Joint Tenant with Right of Survivorship (“JTWROS”)______

Tenants in Common                                                                ______

Tenants by the Entirety                                                          ______

Community Property                                                               ______

Pension or Profit Sharing                                 _______

IRA                                                                      _______

Corporation, Partnership

Trust, Association or

Other Entity                                                        _______

2. Subscriber Information:

	
Name of Applicant, Custodian, Corporation, Trust or Beneficiary

	  
	
Male or Female

	  
	
Date of Birth

	  
	
Soc. Sec./Tax ID #

	  
	
Please check here if this Soc. Sec/Tax ID # is responsible for taxes. We will report this number to the IRS.

	  

	
Name of Joint Tenant or Trustee (if applicable)

	  
	
Male or Female

	  
	
Date of Birth

	  
	
Soc. Sec./Tax ID #

	  
	
Please check here if this Soc. Sec/Tax ID # is responsible for taxes. We will report this number to the IRS.

	  

	
Name of Additional Trustee (if applicable)

	  

 

3. Marital Status:       ________________________

 

 

 

 

 

  

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4. Investment Amount:

Number of Units       __________

Investment Amount (Number of Units x $25,000/unit)  $ _____________

5. Contact Information (This address will be used for mailing unless you indicate otherwise):

INDIVIDUAL CONTACT INFORMATION:

____________________________________________________________

Street Address                                                      Unit #

____________________________________________________________

City, State                                                              Zip Code

____________________________________________________________

Home Phone Number (with area code)

____________________________________________________________

Fax Number (with area code)

____________________________________________________________

Email Address

ENTITY CONTACT INFORMATION:

____________________________________________________________

Name of Company

____________________________________________________________

Contact Name

____________________________________________________________

Street Address                                                      Suite/Floor

____________________________________________________________

City, State                                                              Zip Code

____________________________________________________________

Business Phone Number (with area code)

____________________________________________________________

Fax Number (with area code)

____________________________________________________________

Email Address

 

 

 

 

 

 

  

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6. Type of Government Issued Identification:

____________________________________________________________

Type of Government Issued Identification

____________________________________________________________

Place of Issuance

____________________________________________________________

Identification Number

7.  Beneficial Ownership of Company Securities:

 

Please list all securities of the Company (other than the Units for which you are subscribing) that you own:

 

	
Number of Securities

	
Type of Company Securities (e.g., shares of Common Stock)

	
  

 

	  
	
  

 

	  

8.  Broker-Dealer Status:

 

	
  

	
(a)

	
Are you a broker-dealer?

 

Yes  ________           No  __________

 

	
  

	
Note:

	
If yes, the staff of the Securities and Exchange Commission has indicated that you should be identified as an underwriter in the Registration Statement.

 

	
  

	
(b)

	
Are you an affiliate of a broker-dealer?

 

Yes  ________           No  __________

 

	
  

	
(c)

	
If you are an affiliate of a broker-dealer, do you certify that you bought the Units in the ordinary course of business, and at the time of the purchase of the Units (the securities underlying which will be registrable under the Registration Rights Agreement (the “Registrable Securities”), you had no agreements or understandings, directly or indirectly, with any person to distribute the Registrable Securities?

 

Yes  ________           No  __________

 

 

 

 

 

 

  

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Note:

	
If your response to the foregoing question is “No”, the Commission’s staff has indicated that you should be identified as an underwriter in the Registration Statement relating to the Registrable Securities.

 

9.  Relationships with the Company:

 

Except as set forth below, neither the undersigned nor any of its affiliates, officers, directors or principal equity holders (owners of 5% of more of the equity securities of the undersigned) has held any position or office or has had any other material relationship with the Company (or its predecessors or affiliates) during the past three years.

 

	
  

	
State any exceptions here:

 

 

 

 

 

 

SECTION III

ACCREDITED INVESTOR QUESTIONNAIRE

To be an Accredited Investor, you must meet one of the following tests. Please check the appropriate spaces below.

A.       Individual Accounts

I certify that I am an "accredited investor" because:

 

1. _______ I had an individual income of more than $200,000 in each of the two most recent calendar years, and I reasonably expect to have an individual income in excess of $200,000 in the current calendar year; or my spouse and I had joint income in excess of $300,000 in each of the two most recent calendar years, and we reasonably expect to have a joint income in excess of $300,000 in the current calendar year

 

If you checked “yes” to paragraph 1, please specify the dollar amount of your income in calendar years 2011 and 2012 and your projected income for 2013:

2011                  $____________________

2012                  $____________________

2013                  $____________________ (projected)

Please describe type of income:

 

Individual                      _____

Joint                               _____

Trust                              _____

Beneficiary                    _____

Shareholder                   _____

Partner                            _____

Current occupation: ____________________________________________

 

 

 

 

 

 

  

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Name of employer: _____________________________________________

 

Position or Title: _______________________________________________

 

Phone Number: ________________________________________________

 

Former employment (if current employment is less than five years):

 

Name of employer: _____________________________________________

 

Position or Title: _______________________________________________

 

Period Employed: ______________________________________________

; OR,

 

2. _______ I have an individual net worth, or my spouse and I have a joint net worth, in excess of $1,000,000 (excluding home and personal property).

For purposes of this Subscription Agreement, "individual income" means "adjusted gross income" as reported for Federal income tax purposes, exclusive of any income attributable to a spouse or to property owned by a spouse:  (i) the amount of any interest income received which is tax-exempt under Section 103 of the Internal Revenue Code of 1986, as amended, (the "Code"), (ii) the amount of losses claimed as a limited partner in a limited partnership (as reported on Schedule E of form 1040), (iii) any deduction claimed for depletion under Section 611 et seq. of the Code and (iv) any amount by which income from long-term capital gains has been reduced in arriving at adjusted gross income pursuant to the provisions of Sections 1202 of the Internal Revenue Code as it was in effect prior to enactment of the Tax Reform Act of 1986.

For purposes of this Subscription Agreement, "joint income" means, "adjusted gross income," as reported for Federal income tax purposes, including any income attributable to a spouse or to property owned by a spouse, and increased by the following amounts:  (i) the amount of any interest income received which is tax-exempt under Section 103 of the Internal Revenue Code of 1986, as amended (the "Code"), (ii) the amount of losses claimed as a limited partner in a limited partnership (as reported on Schedule E of Form 1040), (iii) any deduction claimed for depletion under Section 611 et seq. of the Code and (iv) any amount by which income from long-term capital gains has been reduced in arriving at adjusted gross income pursuant to the provisions of Section 1202 of the Internal Revenue Code as it was in effect prior to enactment of the Tax Reform Act of 1986.

For the purposes of the Subscription Agreement, "net worth" means (except as otherwise specifically defined) the excess of total assets at fair market value, including home and personal property, over total liabilities, including mortgages and income taxes on unrealized appreciation of assets.

B.            Corporations, Partnerships, Employee Benefit Plans or IRA

	
1.    

	
Has the subscribing entity been formed for the specific purpose of investing in the Units?  _____________ (yes/no)

 

 

 

 

 

 

  

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If your answer to question 1 is "No," CHECK whichever of the following statements (a-e) is applicable to the subscribing entity. If your answer to question 1 is "Yes," the subscribing entity must be able to certify to statement (2) below in order to qualify as an "accredited investor."

The undersigned entity certifies that it is an “accredited investor” because it is:

(a)      _______ an employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974, provided that the investment decision is made by a plan fiduciary, as defined in section 3(21) of such Act, and the plan fiduciary is a bank, savings and loan association, insurance company or registered investment adviser; or

(b)      _______ an employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974 that has total assets in excess of $5,000,000; or

(c)      _______ each of its shareholders, partners, or beneficiaries meets at least one of the conditions described above under Section IV, A, Individual Accounts. Please also CHECK the appropriate space in that section; or

(d)      _______ the plan is a self directed employee benefit plan and the investment decision is made solely by a person that meets at least one of the conditions described above under Section IV, A, Individual Accounts. Please also CHECK the appropriate space in that section; or

(e)      _______ a corporation, a partnership or a Massachusetts or similar business trust with total assets in excess of $5,000,000.

 

2.     If the answer to Question B.1. above is "Yes," please certify the statement below is true and correct:

_______ The undersigned entity certifies that it is an accredited investor because each of its shareholder or beneficiaries meets at least one of the conditions described above under Section IV, A, Individual Accounts. Please also CHECK the appropriate space in that section.

C.  TRUST ACCOUNT

 

1.        Has the subscribing entity been formed for the specific purpose of investing in the Units?_______________ (yes/no)

 

If your answer to question 1 is "No," CHECK whichever of the following statements (a-c) is applicable to the subscribing entity. If your answer to question 1 is "Yes," the subscribing entity must be able to certify to the statement (c) below in order to qualify as an "accredited investor".

 

The undersigned trustee certifies that the trust is an "accredited investor" because:

 

(a)_______ the trust has total assets in excess of $5,000,000 and the investment decision has been made by a "sophisticated person;" or (Note: Complete Section 2 below to show that the investment decision was made by a “sophisticated person”);

 

(b)_______ the trustee making the investment decision on its behalf is a bank (as defined in Section 3(a)(2) of the Act), a saving and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act, acting in its fiduciary capacity; or,

 

 

 

 

 

  

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(c)_______ the grantor(s) of the trust may revoke the trust at any time and regain title to the trust assets and has (have) retained sole investment control over the assets of the trust and the (each) grantor(s) meets at least one of the conditions described above under Section IV, A, Individual Accounts. Please also CHECK the appropriate space in that section.

 

2.         Investment Experience and Net Worth

 

If you checked 1(a) above, the following information is to be provided by the individual making the investment decision.

 

(a)           Business or professional education (school, dates of attendance, degrees):

 

 

 

(b)            Details of any training or experience in financial, business or tax matters not disclosed in Item 1 immediately above:

 

 

 

 

(c)            Please circle an option below to indicate the frequency of your investments in marketable securities (i.e., securities trading on the public markets):

Often                      Occasionally                                Seldom                                Never

 

(d)            Please state the approximate number and total dollar amount of your prior investments in restricted securities (e.g., private placements):

 

Total Number _______________  Total Amount Invested: $_________________

(e)            My current net worth, after making this investment and exclusive of homes, furnishings, and automobiles is: $__________

3.     Investment Objective:  The undersigned hereby certifies that (a) they have read the Private Placement Memorandum, including, without limitation, the section entitled “Risk Factors,” (b) their investment objective is to invest in speculative securities in order to achieve maximum returns, and accordingly to speculate in micro-cap entities such as the Company, and (c) an investment in the Company’s speculative securities is suitable for the undersigned’s their investment profile. (Please initial to acknowledge that you have approved this statement) __________________

D.   Any Entity (but not an individual person)

______ All of the equity owners of this entity are accredited investors. (If you are checking this option EACH owner of the entity must complete Section III, A, Individual Accounts, by checking option 1 or 2 or both, as applicable. Make copies to do this and note each owner’s name on each copy.)

 

 

 

 

  

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SECTION IV

PATRIOT ACT INFORMATION

The Patriot Act requires us to obtain the following information from you to detect and prevent the misuse of the world financial system.

1.             The Company is required to verify the source of funds. Summarize the underlying source of the funds remitted to us (for example, where subscription monies were the profits of business (and if so please specify type of business), investment income, savings, etc.).

 

Source of Funds:

 

 

2.             In the space provided below, please provide details of where monies were transferred from to the Company in relation to your subscription for the Units.

 

	
COUNTRY

	
NAME OF BANK/

FINANCIAL INSTITUTION

	
CONTACT NAME/PHONE 

NUMBER AT 

BANK/FINANCIAL INSTITUTION

	
NAME OF 

ACCOUNTHOLDER

	
ACCOUNT

NUMBER

	
 

 

	  	  	  	  
	
 

 

	  	  	  	  

If the country from which the monies were transferred appears in the Approved Country List below, please go to Section VIII. If the country does not appear, please go to number 3.

Approved Country List

	
Argentina

	
Germany

	
Liechtenstein

	
Spain

	
Australia

	
Gibraltar

	
Luxembourg

	
Switzerland

	
Bermuda

	
Guernsey

	
Mexico

	
Turkey

	
Belgium

	
Hong Kong

	
Netherlands

	
United Kingdom

	
Brazil

	
Iceland

	
New Zealand

	
United States

	
British Virgin Islands

	
Ireland

	
Norway

	
Canada

	
Isle of Man

	
Panama

	
Denmark

	
Italy

	
Portugal

	
Finland

	
Japan

	
Singapore

	
France

	
Jersey

	
Sweden

	  

 

 

 

 

  

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3.

	
If subscription monies were transferred to the Company from any country other than on the "Approved Country List" (see above), please provide the following documentation to the Company (all copies should be in English and certified as being "true and correct copies of the original" by a notary public of the jurisdiction of which you are resident).

	
(a)  

	
For Individuals:

	
(i)  

	
A clear copy of individual’s passport or valid form of government issued identification (e.g., driver’s license) providing evidence of name, signature, date of birth and photographic identification;

	
(ii)  

	
evidence of permanent address; and

	
(iii)  

	
where possible, a reference from a bank with whom the individual maintains a current relationship and has maintained such relationship for at least two years.

	
(b)  

	
For Companies:

	
(i)  

	
a copy of its certificate of incorporation and any change of name certificate;

	
(ii)  

	
a certificate of good standing;

	
(iii)  

	
a register or other acceptable list of directors and officers;

	
(iv)  

	
a properly authorized mandate of the company to subscribe in the form, for example, of a certified resolution which includes naming authorized signatories;

	
(v)  

	
a description of the nature of the business of the company;

	
(vi)  

	
identification, as described above for individuals, for at least two directors and authorized signatories;

	
(vii)  

	
a register of members or list of shareholders holding a controlling interest; and

	
(viii)  

	
identification, as described above, for individuals who are beneficial owners of corporate shareholders which hold 10% or more of the capital share of the company.

	
(c)  

	
For Partnerships and Unincorporated Businesses:

	
(i)  

	
a copy of any certificate of registration and a certificate of good standing, if registered;

	
(ii)  

	
identification, as described above, for individuals and, where relevant, companies constituting a majority of the partners, owners or managers and authorized signatories;

	
(iii)  

	
a copy of the mandate from the partnership or business authorizing the subscription in the form, for example, of a certified resolution which includes naming authorized signatories; and

 

 

 

 

  

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(iv)  

	
a copy of constitutional documents (formation and partnership agreements).

 

	
(d)  

	
For Trustees:

	
(i)  

	
identification, as described above, for individuals or companies (as the case may be) in respect of the trustees;

	
(ii)  

	
identification, as described above for individuals, of beneficiaries, any person on whose instructions or in accordance with those wishes the trustee/nominee is prepared or accustomed to act and the settlor of the trust; and

 

	
(iii)  

	
evidence of the nature of the duties or capacity of the trustee.

 

 

 

 

 

 

  

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SECTION V

SIGNATURES

The Subscription Agreement contains various statements and representations by subscribers and should be carefully reviewed in its entirety before executing this signature page.

BY SIGNING, I ACKNOWLEDGE THAT I HAVE CAREFULLY REVIEWED THE TRANSACTIONDOCUMENTS RELATED TO THIS INVESTMENT AND AM BOUND BY THE TERMS OF THE TRANSACTION DOCUMENTS AND THIS SUBSCRIPTION AGREEMENT.

Dated: __________________

	
Print name of individual subscriber, custodian, corporation, 

person, trustee

 

 

 

	 	
Signature of individual subscriber, authorized person, 

authorized trustee

 

 

 

	  	 	  
	
Print name of co-subscriber, authorized person, 

co-trustee if required by trust instrument

 

 

 

	 	
Signature of co-subscriber, authorized person, 

co-trustee if required by trust instrument

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

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PURCHASER SIGNATURE PAGES TO SECURITIES PURCHASE AGREEMENT

IN WITNESS WHEREOF, the undersigned have caused this Securities Purchase Agreement to be duly executed by their respective authorized signatories as of the date first indicated above.

 

 

 

	
Name of Purchaser:

	
 

	
Signature of Authorized Signatory of Purchaser:

	  
	
Name of Authorized Signatory:

	
 

	
Title of Authorized Signatory:

	
 

	
Email Address of Authorized Signatory:

	
 

	
Facsimile Number of Authorized Signatory:

	
 

Address for Notice to Purchaser:

 

 

 

 

 

Address for Delivery of Securities to Purchaser (if not same as address for notice):

 

 

 

 

Subscription Amount:            $_____________

Number of Units Purchased     _____________

 

 

 

 

 

 

  

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PURCHASER SIGNATURE PAGES TO REGISTRATION RIGHTS AGREEMENT

 

IN WITNESS WHEREOF, the parties hereto have caused this Registration Rights Agreement to be duly executed by their respective authorized persons as of the date first indicated above.

ASSURED PHARMACY, INC.

 

By:                                                                                          

Name:  Robert DelVecchio

Title:    Chief Executive Officer

 

 

PURCHASERS:

 

By:        ___________________________________

Name:

Title:

 

 

 

 

 

 

 

  

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