Document:

Exhibit 4.1

                       INCORPORATED UNDER THE LAWS OF THE
                                STATE OF NEVADA

                           Your Digital Memories, Inc.

                   TOTAL AUTHORIZED ISSUE 150,000,000 SHARES

<TABLE>
<CAPTION>
<S>                                            <C>
100,000,000 SHARES PAR VALUE $.0001 EACH          50,000,000 SHARES PAR VALUE $.0001 EACH
          COMMON STOCK                                        PREFERRED STOCK
</TABLE>

This is to certify that ________________________________________ is the owner of

--------------------------------------------------------------------------------
           FULLY PAID AND NON-ASSESABLE SHARES OF PREFERRED STOCK OF
                           Your Digital Memories, Inc.

transferrable  on the books of the corporation by the holder hereof in person or
by  duly  authorized  Attorney  upon  surrender  of  this  Certificate  properly
endorsed.

Witness the seal of the  corporation  and the signatures of its duly  authorized
officers.

Dated:

Secretary                                                              President

                                      SealExhibit 10.1

                           Your Digital Memories, Inc.
                          15 Zichron Ya'akov, Suite 23
                                   Entrance B.
                                 Jerusalem 94421

                       REGULATION S SUBSCRIPTION AGREEMENT
                          AND INVESTMENT REPRESENTATION

                                   SECTION 1.

1.1 Subscription.

     (a) The  undersigned,  intending to be legally  bound,  hereby  irrevocably
subscribes for and agrees to purchase  ____________ shares (the "Shares") of the
common  stock (the  "Common  Stock")  of Your  Digital  Memories,  Inc, a Nevada
corporation  (the  "Company")  in a  transaction  exempt  from the  registration
requirements of the Securities Act of 1933, as amended (the  "Securities  Act").
The undersigned understands that the Shares are being sold in connection with an
offering  by the Company of an  aggregate  of up to  1,500,000  shares of Common
Stock for total proceeds of up to $75,000.

1.2 Purchase of Shares.

     The undersigned  understands and acknowledges that the purchase price to be
remitted to the Company in exchange for the Shares shall be ____________ dollars
($______)  or $0.05 per  Share.  The  Company  shall  deliver  the Shares to the
undersigned promptly after the acceptance of this Subscription  Agreement by the
Company.

1.3 Acceptance or Rejection.

     (a) The undersigned  understands  and agrees that the Company  reserves the
right to reject this subscription for the Shares if, in its reasonable judgment,
it deems such action in the best  interest of the Company,  at any time prior to
the  Closing,  notwithstanding  prior  receipt by the  undersigned  of notice of
acceptance of the undersigned's subscription.

     (b) The undersigned  understands and agrees that its  subscription  for the
Shares is irrevocable.

     (c) In the event the sale of the Shares  subscribed for by the  undersigned
is  not  consummated  by the  Company  for  any  reason  (in  which  event  this
Subscription  Agreement  shall be  deemed  to be  rejected),  this  Subscription
Agreement and any other  agreement  entered into between the undersigned and the
Company relating to this  subscription  shall thereafter have no force or effect
and the Company shall promptly return or cause to be returned to the undersigned
<PAGE>
the purchase price remitted to the Company by the undersigned,  without interest
thereon or deduction therefrom, in exchange for the Shares.

                                   SECTION 2.

2.1 Closing. The closing (the "Closing") of the purchase and sale of the Shares,
shall  occur   simultaneously   with  the  acceptance  by  the  Company  of  the
undersigned's  subscription,  as  evidenced by the  Company's  execution of this
Subscription Agreement.

                                   SECTION 3.

3.1  Investor   Representations   and   Warranties.   The   undersigned   hereby
acknowledges,  represents  and warrants to, and agrees with, the Company and its
affiliates as follows:

     (a) Investment  Purposes.  The  undersigned is acquiring the Shares for his
own account as principal,  not as a nominee or agent,  for  investment  purposes
only, and not with a view to, or for, resale,  distribution or fractionalization
thereof  in  whole  or in part and no other  person  has a  direct  or  indirect
beneficial  interest  in  such  Shares  or any  portion  thereof.  Further,  the
undersigned  does not have any contract,  undertaking,  agreement or arrangement
with any person to sell,  transfer or grant  participations to such person or to
any third  person,  with  respect  to the Shares  for which the  undersigned  is
subscribing or any part of the Shares.

     (b) Authority.  The  undersigned has full power and authority to enter into
this  Agreement,  the  execution  and delivery of this  Agreement  has been duly
authorized,  if applicable,  and this Agreement  constitutes a valid and legally
binding obligation of the undersigned.

     (c) No General  Solicitation.  The  undersigned is not  subscribing for the
Shares as a result of or subsequent  to any  advertisement,  article,  notice or
other  communication  published in any  newspaper,  magazine or similar media or
broadcast over television or radio,  or presented at any seminar or meeting,  or
any  solicitation  of a  subscription  by  person  previously  not  known to the
undersigned in connection with investment securities generally.

     (d) No Obligation to Register Shares. The undersigned  understands that the
Company is under no obligation to register the Shares under the Securities  Act,
or to  assist  the  undersigned  in  complying  with the  Securities  Act or the
securities   laws  of  any  state  of  the  United  States  or  of  any  foreign
jurisdiction.

     (e) Investment  Experience.  The  undersigned is (i)  experienced in making
investments of the kind described in this Agreement, (ii) able, by reason of the
business  and   financial   experience  of  its  officers  (if  an  entity)  and
professional  advisors (who are not affiliated with or compensated in any way by
the  Company or any of its  affiliates  or selling  agents),  to protect its own
interests in connection with the transactions  described in this Agreement,  and
(iii) able to afford the entire loss of its investment in the Shares.

                                       2
<PAGE>
     (f)  Exemption  from   Registration.   The  undersigned   acknowledges  his
understanding  that the offering and sale of the Shares is intended to be exempt
from registration under the Securities Act. In furtherance  thereof, in addition
to the other  representations and warranties of the undersigned made herein, the
undersigned  further  represents and warrants to and agrees with the Company and
its affiliates as follows:

          (1) The undersigned  realizes that the basis for the exemption may not
be present if, notwithstanding such representations, the undersigned has in mind
merely acquiring the Shares for a fixed or determinable period in the future, or
for a market rise, or for sale if the market does not rise. The undersigned does
not have any such intention;

          (2) The  undersigned  has the  financial  ability to bear the economic
risk of his  investment,  has adequate means for providing for his current needs
and personal  contingencies  and has no need for  liquidity  with respect to his
investment in the Company; and

          (3) The undersigned has such knowledge and experience in financial and
business  matters  as to be capable  of  evaluating  the merits and risks of the
prospective investment in the Shares. The undersigned also represents it has not
been organized for the purpose of acquiring the Shares; and

          (4) The  undersigned has been provided an opportunity for a reasonable
period  of time  prior to the  date  hereof  to  obtain  additional  information
concerning the offering of the Shares,  the Company and all other information to
the extent the  Company  possesses  such  information  or can acquire it without
unreasonable effort or expense.

     (g) Economic Considerations. The undersigned is not relying on the Company,
or its affiliates or agents with respect to economic  considerations involved in
this investment. The undersigned has relied solely on its own advisors.

     (h) No Other Company Representations. No representations or warranties have
been made to the undersigned by the Company,  or any officer,  employee,  agent,
affiliate or subsidiary of the Company,  other than the  representations  of the
Company contained  herein,  and in subscribing for Shares the undersigned is not
relying upon any representations other than those contained herein.

     (i) Compliance with Laws. Any resale of the Shares during the `distribution
compliance  period' as defined in Rule 902(f) to Regulation S shall only be made
in  compliance  with  exemptions  from  registration  afforded by  Regulation S.
Further,  any such sale of the Shares in any jurisdiction  outside of the United
States will be made in compliance with the securities laws of such jurisdiction.
The  Investor  will not  offer to sell or sell the  Shares  in any  jurisdiction
unless the Investor obtains all required consents, if any.

     (j) Regulation S Exemption. The undersigned understands that the Shares are
being offered and sold to him in reliance on an exemption from the  registration
requirements of United States federal and state securities laws under Regulation
S promulgated  under the Securities Act and that the Company is relying upon the

                                       3
<PAGE>
truth   and   accuracy   of   the   representations,   warranties,   agreements,
acknowledgments  and understandings of the Investor set forth herein in order to
determine  the  applicability  of such  exemptions  and the  suitability  of the
Investor to acquire the Shares.  In this  regard,  the  undersigned  represents,
warrants and agrees that:

          (1) The undersigned is not a U.S. Person (as defined below) and is not
an affiliate (as defined in Rule 501(b) under the Securities Act) of the Company
and is not acquiring the Shares for the account or benefit of a U.S.  Person.  A
U.S. Person means any one of the following:

               (A) any natural person resident in the United States of America;

               (B) any  partnership  or  corporation  organized or  incorporated
under the laws of the United States of America;

               (C) any estate of which any executor or  administrator  is a U.S.
person;

               (D) any trust of which any trustee is a U.S. person;

               (E) any  agency  or branch of a  foreign  entity  located  in the
United States of America;

               (F) any non-discretionary  account or similar account (other than
an estate  or trust)  held by a dealer or other  fiduciary  for the  benefit  or
account of a U.S. person;

               (G) any  discretionary  account or similar account (other than an
estate or trust) held by a dealer or other fiduciary organized,  incorporated or
(if an individual) resident in the United States of America; and

               (H) any partnership or corporation if:

                    (i) organized or incorporated  under the laws of any foreign
jurisdiction; and

                    (ii) formed by a U.S. person  principally for the purpose of
investing in securities not registered  under the Securities  Act,  unless it is
organized or  incorporated,  and owned,  by accredited  investors (as defined in
Rule 501(a) under the Securities  Act) who are not natural  persons,  estates or
trusts.

          (2)  At the  time  of  the  origination  of  contact  concerning  this
Agreement  and the date of the  execution  and delivery of this  Agreement,  the
undersigned was outside of the United States.

          (3) The undersigned will not, during the period commencing on the date
of issuance of the Shares and ending on the first  anniversary  of such date, or

                                       4
<PAGE>
such  shorter  period as may be permitted  by  Regulation S or other  applicable
securities  law (the  "Restricted  Period"),  offer,  sell,  pledge or otherwise
transfer the Shares in the United States, or to a U.S. Person for the account or
for the  benefit  of a U.S.  Person,  or  otherwise  in a manner  that is not in
compliance with Regulation S.

          (4) The undersigned  will, after expiration of the Restricted  Period,
offer,   sell,  pledge  or  otherwise  transfer  the  Shares  only  pursuant  to
registration under the Securities Act or an available  exemption  therefrom and,
in accordance with all applicable state and foreign securities laws.

          (5) The  undersigned  was not in the United  States,  engaged  in, and
prior to the expiration of the  Restricted  Period will not engage in, any short
selling of or any hedging  transaction  with  respect to the  Shares,  including
without limitation, any put, call or other option transaction, option writing or
equity swap.

          (6) Neither the undersigned nor or any person acting on his behalf has
engaged,  nor will engage, in any directed selling efforts to a U.S. Person with
respect to the Shares and the Investor and any person  acting on his behalf have
complied  and will  comply  with the  "offering  restrictions"  requirements  of
Regulation S under the Securities Act.

          (7) The  transactions  contemplated  by this  Agreement  have not been
pre-arranged  with a buyer located in the United  States or with a U.S.  Person,
and are not part of a plan or scheme to evade the  registration  requirements of
the Securities Act.

          (8) Neither the  undersigned  nor any person  acting on his behalf has
undertaken  or  carried  out any  activity  for the  purpose  of, or that  could
reasonably  be  expected to have the effect of,  conditioning  the market in the
United  States,  its  territories  or  possessions,  for any of the Shares.  The
undersigned  agrees not to cause any advertisement of the Shares to be published
in any  newspaper or  periodical  or posted in any public place and not to issue
any circular relating to the Shares, except such advertisements that include the
statements  required by Regulation S under the Securities Act, and only offshore
and not in the U.S. or its  territories,  and only in compliance  with any local
applicable securities laws.

          (9) Each  certificate  representing  the Shares shall be endorsed with
the  following  legends,  in addition to any other legend  required to be placed
thereon by applicable federal or state securities laws:

               (A) "THE  SECURITIES  ARE BEING  OFFERED TO INVESTORS WHO ARE NOT
U.S.  PERSONS (AS DEFINED IN REGULATION S UNDER THE  SECURITIES  ACT OF 1933, AS
AMENDED ("THE SECURITIES ACT")) AND WITHOUT  REGISTRATION WITH THE UNITED STATES
SECURITIES  AND EXCHANGE  COMMISSION  UNDER THE  SECURITIES ACT IN RELIANCE UPON
REGULATION S PROMULGATED UNDER THE SECURITIES ACT."

                                       5
<PAGE>
               (B)  "TRANSFER  OF THESE  SECURITIES  IS  PROHIBITED,  EXCEPT  IN
ACCORDANCE WITH THE PROVISIONS OF REGULATION S, PURSUANT TO  REGISTRATION  UNDER
THE  SECURITIES  ACT, OR  PURSUANT TO  AVAILABLE  EXEMPTION  FROM  REGISTRATION.
HEDGING  TRANSACTIONS  MAY  NOT BE  CONDUCTED  UNLESS  IN  COMPLIANCE  WITH  THE
SECURITIES ACT."

          (10) The undersigned  consents to the Company making a notation on its
records or giving  instructions to any transfer agent of the Company in order to
implement the  restrictions  on transfer of the Shares set forth in this Section
3.

     (k) Accredited  Investor.  The  undersigned is an "accredited  investor" as
that term is defined in Rule 501 of the General Rules and Regulations  under the
Securities Act by reason of Rule 501(a)(3).

     (l) Potential Loss of Investment; Risk Factors. The undersigned understands
that an investment in the Shares is a speculative  investment  which  involves a
high  degree  of risk  and the  potential  loss of his  entire  investment.  The
undersigned  understands that the following factors,  among others,  could cause
the loss of any or all of his investment.

          (1) The  Company is a  development  stage  company  with no  operating
history  for  the  undersigned  to  evaluate  its  business.   The  Company  was
incorporated in the State of Nevada in June 2006, and as a result is only in the
very early stages of development.  Because the Company has no operating history,
it is difficult to evaluate its business and future  prospects.  The undersigned
has also considered the uncertainties and difficulties frequently encountered by
companies,  such as the  Company,  in their  early  stages of  development.  The
Company's  revenue and income  potential is unproven  and its business  model is
still  emerging.  If its  business  model does not prove to be  profitable,  the
undersigned may lose all of his investment.

          (2) The  Company  currently  does not have enough  working  capital to
satisfy its capital needs.  The Company is dependent upon its management team to
fund its ongoing operations, and cannot be certain that future financing will be
available  to it on  acceptable  terms when it needs it. The Company can give no
assurances  that it will be able to sell any  portion of this  offering  or that
management will continue to fund its ongoing  operations.  This,  along with the
possibility of other factors and circumstances  the Company cannot predict,  may
require it to seek additional financing faster than anticipated.  If the Company
is unable to obtain financing to meet its needs, the undersigned may lose of his
investment.

          (3) The Company's  officers and  directors  will only devote a limited
amount of time to the Company.  Their divided interests may hinder the Company's
ability to generate revenue. This could result in missed business  opportunities
and  worse-than-expected  operating results. The undersigned may lose his entire
investment.

          (4)  Management has never operated in the industry in which it intends
to  operate.  This lack of  experience  may result in the  Company's  needing to
employ outside  experts that have such  experience.  The  additional  cost could
result in a net operating  loss and,  ultimately,  could result in the Company's

                                       6
<PAGE>
failure.  Management's  inexperience may limit the Company's ability to generate
revenues.  The  Company  may  never  achieve  successful  operations,   and  the
undersigned may lose his entire investment.

     (m)  Investment   Commitment.   The  undersigned's  overall  commitment  to
investments  which are not readily  marketable  is not  disproportionate  to the
undersigned's  net worth,  and an  investment  in the Shares will not cause such
overall commitment to become excessive.

     (n) Receipt of  Information.  The  undersigned  has received all documents,
records, books and other information pertaining to the undersigned's  investment
in the Company that has been requested by the undersigned.

     (o) Investor Questionnaire.  The undersigned represents and warrants to the
Company that all  information  that the undersigned has provided to the Company,
including,  without  limitation,  the information in the Investor  Questionnaire
attached  hereto  as  Exhibit  1 or  previously  provided  to the  Company  (the
"Investor Questionnaire"), is correct and complete as of the date hereof.

     (p) No Reliance.  Other than as set forth herein,  the  undersigned  is not
relying upon any other information, representation or warranty by the Company or
any officer,  director,  stockholder,  agent or representative of the Company in
determining  to invest in the Shares.  The  undersigned  has  consulted,  to the
extent  deemed  appropriate  by the  undersigned,  with  the  undersigned's  own
advisers as to the  financial,  tax,  legal and related  matters  concerning  an
investment in the Shares and on that basis  believes that his or its  investment
in the Shares is suitable and appropriate for the undersigned.

     (q) No  Governmental  Review.  The  undersigned is aware that no federal or
state  agency has (i) made any finding or  determination  as to the  fairness of
this investment,  (ii) made any  recommendation  or endorsement of the Shares or
the Company,  or (iii) guaranteed or insured any investment in the Shares or any
investment made by the Company.

     (r) Price of  Shares.  The  undersigned  understands  that the price of the
Shares offered hereby bear no relation to the assets, book value or net worth of
the Company and were  determined  arbitrarily  by the Company.  The  undersigned
further  understands that there is a substantial risk of further dilution on his
or its investment in the Company.

                                   SECTION 4.

4.1  Company's  Representations  and  Warranties.  The  Company  represents  and
warrants to the undersigned as follows:

     (a)  Organization  of  the  Company.  The  Company  is a  corporation  duly
organized and validly  existing and in good standing under the laws of the State
of Nevada.

     (b)  Authority.  (a) The  Company  has the  requisite  corporate  power and
authority to enter into and perform its obligations  under this Agreement and to
issue the  Shares;  (b) the  execution  and  delivery of this  Agreement  by the

                                       7
<PAGE>
Company and the consummation by it of the transactions  contemplated  hereby and
thereby  have been duly  authorized  by all  necessary  corporate  action and no
further  consent or  authorization  of the Company or its Board of  Directors or
stockholders  is required;  and (c) this  Agreement  has been duly  executed and
delivered by the Company and  constitutes a valid and binding  obligation of the
Company  enforceable against the Company in accordance with its terms, except as
such  enforceability  may be limited by applicable  bankruptcy,  insolvency,  or
similar laws relating to, or affecting  generally the enforcement of, creditors'
rights and remedies or by other equitable principles of general application.

     (c) Exemption from Registration;  Valid Issuances. The sale and issuance of
the Shares, in accordance with the terms and on the bases of the representations
and warranties of the  undersigned  set forth herein,  may and shall be properly
issued by the Company to the undersigned  pursuant to any applicable  federal or
state law. When issued and paid for as herein provided, the Shares shall be duly
and validly  issued,  fully paid,  and  nonassessable.  Neither the sales of the
Shares pursuant to, nor the Company's performance of its obligations under, this
Agreement shall (a) result in the creation or imposition of any liens,  charges,
claims  or  other  encumbrances  upon the  Shares  or any of the  assets  of the
Company,  or (b) entitle the other holders of the Common Stock of the Company to
preemptive  or other rights to subscribe to or acquire the Common Stock or other
securities  of the  Company.  The Shares  shall not subject the  undersigned  to
personal liability by reason of the ownership thereof.

     (d) No General  Solicitation or Advertising in Regard to this  Transaction.
Neither the Company nor any of its  affiliates  nor any person  acting on its or
their behalf (a) has conducted or will conduct any general solicitation (as that
term is used in Rule 502(c) of Regulation D) or general advertising with respect
to any of the  Shares,  or (b) made any  offers  or  sales  of any  security  or
solicited  any offers to buy any  security  under any  circumstances  that would
require registration of the Common Stock under the Securities Act.

                                   SECTION 5.

5.1  Indemnity.  The  undersigned  agrees to  indemnify  and hold  harmless  the
Company,  its officers and  directors,  employees and its  affiliates  and their
respective  successors  and assigns and each other person,  if any, who controls
any thereof,  against any loss, liability,  claim, damage and expense whatsoever
(including,  but not  limited  to, any and all  expenses  whatsoever  reasonably
incurred  in  investigating,  preparing  or  defending  against  any  litigation
commenced or  threatened or any claim  whatsoever)  arising out of or based upon
any false  representation or warranty or breach or failure by the undersigned to
comply with any covenant or agreement made by the  undersigned  herein or in any
other  document  furnished  by  the  undersigned  to any  of  the  foregoing  in
connection with this transaction.

5.2  Modification.  Neither this  Agreement nor any  provisions  hereof shall be
modified,  discharged or terminated except by an instrument in writing signed by
the party against whom any waiver, change, discharge or termination is sought.

                                       8
<PAGE>
5.3 Notices.  Any notice,  demand or other  communication which any party hereto
may be required,  or may elect, to give to anyone interested  hereunder shall be
sufficiently  given if (a) deposited,  postage prepaid,  in a United States mail
letter box, registered or certified mail, return receipt requested, addressed to
such  address  as may be  given  herein,  or (b)  delivered  personally  at such
address.

5.4  Counterparts.  This  Agreement may be executed  through the use of separate
signature pages or in any number of counterparts  and by facsimile,  and each of
such counterparts  shall, for all purposes,  constitute one agreement binding on
all parties,  notwithstanding  that all parties are not  signatories to the same
counterpart. Signatures may be facsimiles.

5.5 Binding Effect. Except as otherwise provided herein, this Agreement shall be
binding upon and inure to the benefit of the parties and their heirs, executors,
administrators,   successors,   legal   representatives   and  assigns.  If  the
undersigned is more than one person,  the obligation of the undersigned shall be
joint  and  several  and  the   agreements,   representations,   warranties  and
acknowledgments  herein  contained  shall be deemed to be made by and be binding
upon each such person and his heirs, executors, administrators and successors.

5.6 Entire Agreement. This Agreement and the documents referenced herein contain
the entire agreement of the parties and there are no representations,  covenants
or other agreements except as stated or referred to herein and therein.

5.7  Assignability.  This  Agreement is not  transferable  or  assignable by the
undersigned.

5.8  Applicable  Law.  This  Agreement  shall be  governed by and  construed  in
accordance  with the laws of the State of New  York,  without  giving  effect to
conflicts of law principles.

5.9 Pronouns. The use herein of the masculine pronouns "him" or "his" or similar
terms shall be deemed to include the feminine and neuter genders as well and the
use herein of the  singular  pronoun  shall be deemed to  include  the plural as
well.

5.10 Further  Assurances.  Upon request from time to time, the undersigned shall
execute and deliver all documents, take all rightful oaths and do all other acts
that may be necessary or desirable,  in the reasonable opinion of the Company or
its counsel, to effect the subscription for the Shares in accordance herewith.

                                       9
<PAGE>
     IN WITNESS WHEREOF,  the undersigned has executed this Agreement on the day
of ________________, 2007.

Amount of Investment:

$
 ---------------------

INDIVIDUAL INVESTOR:

By:
   ---------------------

Address:
        ----------------

------------------------

------------------------
     (Signature)

PARTNERSHIP, CORPORATION, TRUST,
CUSTODIAL ACCOUNT, OTHER INVESTOR

------------------------------
 (Name of Entity)

By:
   ---------------------------
Name:
     -------------------------
Title:
      ------------------------
Address:
        ----------------------

Taxpayer Identification Number:_____________

                                       10
<PAGE>
                             INVESTOR QUESTIONNAIRE

A. General Information

     1. Print Full Name of Investor: Individual:

                                     --------------------------------
                                     First, Middle, Last

                                     Partnership, Corporation, Trust,
                                     Custodial Account, Other:

                                     --------------------------------
                                     Name of Entity

     2. Address for Notices:
                                     --------------------------------

                                     --------------------------------

                                     --------------------------------

     3.  Name of Primary Contact Person:
                                        -----------------------------
         Title:

     4. Telephone Number:
                                     --------------------------------

     5. E-Mail Address:
                                     --------------------------------

     6. Facsimile Number:
                                     --------------------------------

     7. Permanent Address:
                                     --------------------------------
     (if different from Address for Notices above)

     8. Authorized Signatory:
                                     --------------------------------

     9.  U.S. Investors Only: U.S. Taxpayer Identification or
     Social Security Number:
                                     --------------------------------

                                       11
<PAGE>
The Investor  understands that the foregoing  information will be relied upon by
the Company for the purpose of  determining  the  eligibility of the Investor to
purchase the Shares.  The Investor  agrees to notify the Company  immediately if
any  representation  or  warranty  contained  in  this  Subscription  Agreement,
including this Investor Questionnaire,  becomes untrue at any time. The Investor
agrees to provide, if requested,  any additional information that may reasonably
be required to substantiate the Investor's  status as an accredited  investor or
to otherwise  determine the  eligibility of the Investor to purchase the Shares.
The Investor agrees to indemnify and hold harmless the Company and each officer,
director,  shareholder,  agent  and  representative  of the  Company  and  their
respective  affiliates  and  successors  and assigns  from and against any loss,
damage or  liability  due to or arising  out of a breach of any  representation,
warranty or agreement of the Investor contained herein.

                                     INDIVIDUAL:

                                              --------------------------
                                                     (Signature)

                                              --------------------------
                                                    (Print Name)

                                     PARTNERSHIP, CORPORATION, TRUST,
                                     CUSTODIAL ACCOUNT, OTHER:

                                              --------------------------
                                                  (Name of Entity)

                                     By:
                                        --------------------------------
                                                    (Signature)

                                              --------------------------
                                                (Print Name and Title)

                                       12

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