Document:

EXHIBIT
4.1

     

    
      	
              THE
      WARRANT AND THE SECURITIES ISSUABLE UPON EXERCISE OF THIS WARRANT
      (COLLECTIVELY, THE “SECURITIES”) HAVE NOT BEEN REGISTERED UNDER THE
      SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR UNDER ANY
      STATE SECURITIES OR BLUE SKY LAWS (“BLUE SKY LAWS”).  NO
      TRANSFER, SALE, ASSIGNMENT, PLEDGE, HYPOTHECATION OR OTHER DISPOSITION OF
      THIS WARRANT OR THE SECURITIES OR ANY INTEREST THEREIN MAY BE MADE EXCEPT
      (A) PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES
      ACT AND ANY APPLICABLE BLUE SKY LAWS OR (B) IF THE CORPORATION HAS BEEN
      FURNISHED WITH BOTH AN OPINION OF COUNSEL FOR THE HOLDER, WHICH OPINION
      AND COUNSEL SHALL BE SATISFACTORY TO THE CORPORATION, TO THE EFFECT THAT
      NO REGISTRATION IS REQUIRED BECAUSE OF THE AVAILABILITY OF AN EXEMPTION
      FROM REGISTRATION UNDER THE SECURITIES ACT AND APPLICABLE BLUE SKY LAWS,
      AND ASSURANCES THAT THE TRANSFER, SALE, ASSIGNMENT, PLEDGE, HYPOTHECATION
      OR OTHER DISPOSITION WILL BE MADE ONLY IN COMPLIANCE WITH THE CONDITIONS
      OF ANY SUCH REGISTRATION OR
EXEMPTION.

            

    

    

    WARRANT
TO PURCHASE SHARES OF COMMON STOCK

    OF

    WITS
BASIN PRECIOUS MINERALS INC.

    

    
      	
              Warrant
      No. [xx]

            	
              Minneapolis,
      Minnesota

            
	 
      	
              [Month
      xx, 20xx]

            

    

    

    THIS
CERTIFIES THAT, for value received, [Name], or its/his successors or assigns
(collectively, the “Holder”) is entitled to
purchase from Wits Basin Precious Minerals Inc. (the “Company”) [Amount] (xxx,xxx)
fully paid and nonassessable shares (the “Shares”) of the Company’s
common stock, $0.01 par value (the “Common Stock”), at an exercise
price of Three Cents ($0.03) per Share (the “Exercise Price”), subject to
adjustment as herein provided.  This Warrant may be exercised by
Holder at any time after the date hereof; provided, however, that,
Holder shall in no event have the right to exercise this Warrant or any portion
thereof after [Month xx, 20xx], at which time all of Holder’s rights hereunder
shall expire.

    

    This
Warrant is subject to the following provisions, terms and
conditions:

    

    1.           Exercise of Warrant.
The rights represented by this Warrant may be exercised by the Holder, in whole
or in part (but not as to a fractional share of Common Stock), by the surrender
of this Warrant (properly endorsed, if required, at the Company’s principal
office in Minneapolis, Minnesota, or such other office or agency of the Company
as the Company may designate by notice in writing to the Holder at the address
of such Holder appearing on the books of the Company at any time within the
period above named), and upon payment to it by certified check, electronic wire
transfer, bank draft or cash of the purchase price for such
Shares.  The Company agrees that the Shares so purchased shall have
and are deemed to be issued to the Holder as the record owner of such Shares as
of the close of business on the date on which this Warrant shall have been
surrendered and payment made for such Shares as aforesaid. Certificates for the
Shares of Common Stock so purchased shall be delivered to the Holder within a
reasonable time, not exceeding fourteen (14) days, after the rights represented
by this Warrant shall have been so exercised, and, unless this Warrant has
expired, a new Warrant representing the number of Shares, if any, with respect
to which this Warrant shall not then have been exercised shall also be delivered
to the Holder within such time.  The Company may require that any such
new Warrant or any certificate for Shares purchased upon the exercise hereof
bear a legend substantially similar to that which is contained on the face of
this Warrant.

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    2.           Transferability of this
Warrant.  This Warrant is issued upon the following terms, to
which Holder consents and agrees:

    

    (a)           Until
this Warrant is transferred on the books of the Company, the Company will treat
the Holder of this Warrant registered as such on the books of the Company as the
absolute owner hereof for all purposes without being affected by any notice to
the contrary.

    

    (b)           This
Warrant may not be exercised, and this Warrant and the Shares underlying this
Warrant shall not be transferable, except in compliance with all applicable
state and federal securities laws, regulations and orders, and with all other
applicable laws, regulations and orders.

    

    (c)           The
Warrant may not be transferred, and the Shares issuable upon the exercise of
this Warrant, may not be transferred without the Holder obtaining an opinion of
counsel, which opinion and counsel are satisfactory to the Company, stating that
the proposed transaction will not result in a prohibited transaction under the
Securities Act and applicable Blue Sky Laws.  By accepting this
Warrant, the Holder agrees to act in accordance with any conditions reasonably
imposed on such transfer by such opinion of counsel.

    

    (d)           Neither
this issuance of this Warrant nor the issuance of the Shares issuable upon
exercise of this Warrant have been registered under the Securities
Act.

    

    3.           Certain Covenants of the
Company.  The Company covenants and agrees that all Shares
which may be issued upon the exercise of the rights represented by this Warrant,
upon issuance and full payment for the Shares so purchased, will be duly
authorized and issued, fully paid and nonassessable and free from all taxes,
liens and charges with respect to the issue hereof, except those that may be
created by or imposed upon the Holder or its property; and without limiting the
generality of the foregoing, the Company covenants and agrees that it will from
time to time take all such actions as may be required to assure that the par
value per share of the Common Stock is at all times equal to or less than the
effective Exercise Price per Share issuable pursuant to this
Warrant.  The Company further covenants and agrees that during the
period within which the rights represented by this Warrant may be exercised, the
Company will at all times have authorized and reserved, free of preemptive or
other rights, for the exclusive purpose of issue upon exercise of the purchase
rights evidenced by this Warrant, a sufficient number of shares of its Common
Stock to provide for the exercise of the rights represented by this
Warrant.

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    4.        
   Adjustment of Exercise Price
and Number of Shares.  The Exercise Price and number of Shares
are subject to the following adjustments:

    

    (a)           Adjustment of Exercise Price
for Stock Dividend, Stock Split or Stock Combination.   In
the event that (i) any dividends on any class of stock of the Company payable in
Common Stock or securities convertible into or exercisable for Common Stock
(“Common Stock
Equivalents”) shall be paid by the Company, (ii) the Company shall
subdivide its then outstanding shares of Common Stock into a greater number of
shares, or (iii) the Company shall combine its outstanding shares of Common
Stock, by reclassification or otherwise, then, in any such event, the Exercise
Price in effect immediately prior to such event shall (until adjusted again
pursuant hereto) be adjusted immediately after such event to a price (calculated
to the nearest full cent) determined by dividing (a) the number of shares of
Common Stock outstanding immediately prior to such event, multiplied by the then
existing Exercise Price, by (b) the total number of shares of Common Stock
outstanding immediately after such event, and the resulting quotient shall be
the adjusted Exercise Price per share.  No adjustment of the Exercise
Price shall be made if the amount of such adjustment shall be less than $0.01
per Share, but in such case any adjustment that would otherwise be required then
to be made shall be carried forward and shall be made at the time and together
with the next subsequent adjustment which, together with any adjustment or
adjustments so carried forward, shall amount to not less than $0.01 per
Share.

    

    (b)           Adjustment of Number of
Shares Issuable upon Exercise of Warrants.  Upon each
adjustment of the Exercise Price pursuant to this Section, the Holder shall
thereafter (until another such adjustment) be entitled to purchase at the
adjusted Exercise Price the number of Shares, calculated to the nearest full
Share, equal to the quotient of (i) the product of (A) the number of Shares
purchasable under this Warrant (as then adjusted pursuant hereto prior to the
current adjustment), multiplied by (B) the Exercise Price in effect prior to
such adjustment, divided by (ii) the adjusted Exercise Price.

    

    (c)           Notice as to
Adjustment.  Upon any adjustment of the Exercise Price and any
increase or decrease in the number of Shares of Common Stock issuable upon the
exercise of the Warrant, then, and in each such case, the Company within thirty
(30) days thereafter shall give written notice thereof, by first class mail,
postage prepaid, addressed to each Holder as shown on the books of the
Company.  Any such notice shall state the adjusted Exercise Price and
adjusted number of Shares issuable upon the exercise of the Warrant, and shall
set forth in reasonable detail the methods of calculation of such adjustments
and the facts upon which such calculations were based.

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    (d)           Effect of Reorganization,
Reclassification, Merger, etc.  If at any time while this
Warrant is outstanding there should be (i) any capital reorganization of the
capital stock of the Company (other than the issuance of any shares of Common
Stock in subdivision of outstanding shares of Common Stock by reclassification
or otherwise and other than a combination of shares provided for in Section 4(a)
hereof), (ii) any consolidation or merger of the Company with another
corporation, or any sale, conveyance, lease or other transfer by the Company of
all or substantially all of its property to any other corporation, which is
effected in such a manner that the holders of Common Stock shall be entitled to
receive cash, stock, securities, or assets with respect to or in exchange for
Common Stock, or (iii) any dividend or any other distribution upon any class of
stock of the Company payable in stock of the Company of a different class, other
securities of the Company, or other property of the Company (other than cash),
then, as a part of such transaction, lawful provision shall be made so that
Holder shall have the right thereafter to receive, upon the exercise hereof, the
number of shares of stock or other securities or property of the Company, or of
the successor corporation resulting from such consolidation or merger, or of the
corporation to which the property of the Company has been sold, conveyed, leased
or otherwise transferred, as the case may be, which the Holder would have been
entitled to receive upon such capital reorganization, reclassification of
capital stock, consolidation, merger, sale, conveyance, lease or other transfer,
if this Warrant had been exercised immediately prior to such capital
reorganization, reclassification of capital stock, consolidation, merger, sale,
conveyance, lease or other transfer.  In any such case, appropriate
adjustments (as determined by the Board of Directors of the Company) shall be
made in the application of the provisions set forth in this Warrant (including
the adjustment of the Exercise Price and the number of Shares issuable upon the
exercise of the Warrant) to the end that the provisions set forth herein shall
thereafter be applicable, as near as reasonably may be, in relation to any
shares or other property thereafter deliverable upon the exercise of the Warrant
as if the Warrant had been exercised immediately prior to such capital
reorganization, reclassification of capital stock, such consolidation, merger,
sale, conveyance, lease or other transfer and the  Holder had carried
out the terms of the exchange as provided for by such capital reorganization,
consolidation or merger.  The Company shall not effect any such
capital reorganization, consolidation, merger or transfer unless, upon or prior
to the consummation thereof, the successor corporation or the corporation to
which the property of the Company has been sold, conveyed, leased or otherwise
transferred shall assume by written instrument the obligation to deliver to the
Holder such shares of stock, securities, cash or property as in accordance with
the foregoing provisions such Holder shall be entitled to purchase.

    

    5.           No Rights as
Shareholder.  This Warrant shall not entitle the Holder as such
to any voting rights or other rights as a shareholder of the
Company.

    

    6.           Registration
Rights.  If at any time the Company shall propose to file any
registration statement (other than any registration on Form S-4, S-8 or any
other similarly inappropriate form, or any successor forms thereto) under the
1933 Act covering a public offering of the Company’s Common Stock (the “Registration Statement”), it
will notify the Holder hereof at least thirty (30) days prior to each such
filing (the “Registration
Notice”) and will use its best efforts to include in the Registration
Statement (to the extent permitted by applicable regulation) the Shares
purchased or purchasable by the Holder upon the exercise of the Warrant to the
extent requested by the Holder hereof within twenty (20) days after receipt of
notice of such filing (which request shall specify the interest in this Warrant
or the Shares intended to be sold or disposed of by such Holder and describe the
nature of any proposed sale or other disposition thereof); provided, however,
that if a greater number of Shares is offered for participation in the proposed
offering than in the reasonable opinion of the managing underwriter of the
proposed offering can be accommodated without adversely affecting the proposed
offering, then the amount of Shares proposed to be offered by such Holder for
registration, as well as the number of securities of any other selling
shareholders participating in the registration, shall be proportionately reduced
to a number deemed satisfactory by the managing underwriter.  The
Company shall bear all expenses and fees incurred in connection with the
preparation, filing, and amendment of the Registration Statement with the
Commission, except that the Holder shall pay all fees, disbursements and
expenses of any counsel or expert retained by the Holder and all underwriting
discounts and commissions, filing fees and any transfer or other taxes relating
to the Shares included in the Registration Statement.  The Holder of
this Warrant agrees to cooperate with the Company in the preparation and filing
of any Registration Statement, and in the furnishing of information concerning
the Holder for inclusion therein, or in any efforts by the Company to establish
that the proposed sale is exempt under the 1933 Act as to any proposed
distribution. The Holder understands that if the Company has not received such
information requested by the Company in the Registration Notice within 20 days
after Holder’s receipt thereof, the Company shall have no obligation to include
any of Holder’s Shares in the Registration Statement.

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    7.           Governing
Law.  This Warrant shall be governed by and construed in
accordance with the laws of the State of Minnesota without regard to its
conflicts-of-law provisions.

    

    8.           Amendments and
Waivers.  The provisions of this Warrant may not be amended,
modified or supplemented, and waiver or consents to departures from the
provisions hereof may not be given, unless the Company agrees in writing and has
obtained the written consent of the Holder.

    

    9.           Redemption of
Warrant.

    

    (a)           Redemption
Price.  This Warrant may be redeemed at the option of the
Company following a period of thirty (30) consecutive trading days where the per
share closing sale price of the Common Stock equals or exceeds Ten Cents
($0.10), on notice as set forth in Section 9(b) hereof, and at a redemption
price equal to One Hundredth of a Cent ($0.001) for each Share purchasable under
this Warrant.

    

    (b)           Notice of
Redemption.  In the case of any redemption of this Warrant, the
Company shall give notice of such redemption to the Holder hereof as provided in
this Section 9(b).  Notice of redemption to the Holder of this Warrant
shall be given by mailing by first-class mail, postage prepaid, a notice of such
redemption not less than thirty (30) trading days prior to the date fixed for
redemption. Any notice which is given in the manner herein provided shall be
conclusively presumed to have been duly given, whether or not the Holder
receives the notice.  Each such notice shall specify the date fixed
for redemption, the place of redemption and the redemption price of $0.001 per
Share at which this Warrant is to be redeemed, and shall state that payment of
the redemption price of the Warrant will be made up on surrender of this Warrant
at such place of redemption, and that if not exercised by the close of business
on the date fixed for redemption, the exercise rights of the Warrant shall
expire unless extended by the Company.  Such notice shall also state
the current Exercise Price and the date on which the right to exercise the
Warrant will expire unless extended by the Company.

    

    (c)           Payment of Redemption
Price.  If notice of redemption shall have been given as
provided in Section 9(b), the redemption price of $0.001 per Share shall, unless
the Warrant is theretofore exercised pursuant to the terms hereof, become due
and payable on the date and at the place stated in such notice.  On
and after such date of redemption, the exercise rights of this Warrant shall
expire.  On presentation and surrender of this Warrant at such place
of payment in such notice specified, this Warrant shall be paid and redeemed at
the redemption price of $0.001 per Share within ten (10) days
thereafter.

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    10.           Successors and
Assigns.  All
the terms and conditions of this Warrant shall be binding upon and inure to the
benefit of the permitted successors and assigns of the Company and
Holder.

    

    11.           Headings and
References.  The
headings of this Warrant are for convenience only and shall not affect the
interpretation of this Warrant.  Unless the context indicates
otherwise, all references herein to Sections are references to Sections of this
Warrant.

    

    12.           Notices.  All
notices or communications hereunder, except as herein otherwise specifically
provided, shall be in writing and if sent to the Holder shall be mailed,
delivered, or transmitted via facsimile and confirmed to the Holder at its or
his address set forth on the records of the Company; or if sent to the Company
shall be mailed, delivered, or transmitted via facsimile and confirmed to Wits
Basin Precious Minerals Inc., 900 IDS Center, 80 South 8th Street,
Minneapolis, Minnesota 55402-8773, facsimile number (612) 395-5276, or to such other address
as the Company or the Holder shall notify the other as provided in this
Section.

     

    IN
WITNESS WHEREOF, Wits Basin Precious Minerals Inc. has caused this Warrant to be
signed by its duly authorized officer in the date set forth above.

    

    
      
        
          	
                  WITS
      BASIN PRECIOUS MINERALS INC.

                
	 
      
	
                  By:

                	 
      
	 
      	
                  Mark
      D. Dacko

                
	 
      	
                  Chief
      Financial OfficerEXHIBIT
10.1

     

    SUBSCRIPTION
AGREEMENT

     

    This
Subscription Agreement (this “Agreement”) is made
by and between Wits Basin Precious Minerals Inc, a Minnesota corporation (the
“Company”),
and:

     

      
        

      

    

     

    (hereinafter
referred to, whether individually or jointly, as the “Undersigned”) in
connection with the private placement offering (the “Offering”) of up to
an aggregate amount of $110,000 in units of the Company (the “Units”), each Unit
consisting of one share of the Company’s common stock, par value $0.01 per share
(the “Common
Stock”), and one warrant to purchase a share of Common Stock at an
exercise price of $0.03 per share, in the form attached hereto as Exhibit A (the “Warrants”), at a
price per Unit of $0.03.  The Company has the right to reject any
subscription, in whole or in part, at any time and for any reason.  If
the subscription is rejected or if the Offering is otherwise terminated, the
Company will promptly return the related funds delivered herewith, without
interest or deduction.  The Offering will continue until August 31,
2010.

     

    1.           Subscription for
Units.  Subject to the terms hereinafter set forth, the
undersigned hereby irrevocably subscribes for and agrees to purchase from the
Company                                                         Units
for an aggregate purchase price of $                                                      
(the “Purchase
Price”).  Payment of the Purchase Price is being delivered
by:

     

    
      	
               
      

            	
               ̈

            	
              an
      enclosed check payable to the order of Wits Basin Precious Minerals Inc
      or

            

    

     

     ̈           a
wire transfer of immediately available funds to:

     

    
      
        	
                Bank

              	
                Wells
      Fargo Bank, N.A. MAC: N9305-011, 6th
      & Marquette Ave Minneapolis, MN 55479

              
	
                Routing
      Number:

              	
                121000248

              
	
                Account
      Number:

              	
                1889094940

              
	
                Account
      Name:

              	
                Wits
      Basin Precious Minerals Inc

              

      

    

    

    Upon
acceptance of this subscription and the closing of the Offering (or any part of
the Offering to which this subscription relates), the Company will record the
undersigned as the holder of the Common Stock and Warrants in the Company’s
records.  The undersigned hereby authorizes the Company to record the
Common Stock and Warrants purchased hereunder as being held by the person(s)
having the mailing address set forth below.

     

    2.           Representations of the
Subscriber.  In connection with, and in consideration of, the
sale of the Units, including the shares of common stock included therein and the
shares of common stock issuable upon exercise of the Warrants (collectively, the
“Securities”),
to the undersigned, the undersigned hereby represents and warrants to the
Company that the undersigned:

     

    A.           Has
received, carefully reviewed and is familiar with (i) the Company’s Annual
Report on Form 10-K for the year ended December 31, 2009 filed with the
Securities and Exchange Commission (the “SEC”) on April 15, 2010; (ii) the
Company’s Quarterly Report on Form 10-Q for the quarter ended March 31, 2010,
filed with the SEC on May 17, 2010 (iii) the Company’s Current Report on Form
8-K filed with the SEC on December 18, 2009; and (iv) any other documents
specifically requested by the Investor (all such documents are collectively
referred to hereinafter as the “Disclosure
Documents”).

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    B.           Has
been given access to full and complete information regarding the Company
(including the opportunity to meet with Company officers and review all
documents as the undersigned may have requested in writing and the opportunity
to ask any questions the undersigned may have had) and has utilized such access
to the undersigned’s satisfaction for the purpose of obtaining information in
addition to, or verifying information included in, the Disclosure Documents to
the extent reasonably available, necessary to verify the accuracy of information
provided in the Disclosure Documents.

     

    C.           The
undersigned further understands that the Securities have not been registered
under the Securities Act of 1933, as amended (the “Act”), and there
currently is no market for the Company’s common stock.

     

    D.           The
undersigned realizes that there are significant restrictions on the
transferability of the Securities and that for these and other reasons, the
undersigned may not be able to liquidate an investment in the Securities for an
indefinite period.

     

    E.           Can
bear the economic risk of an investment in the Securities for an indefinite
period of time, can afford to sustain a complete loss of such investment, has no
need for liquidity in connection with an investment in the Securities, and can
afford to hold the Securities indefinitely.

     

    F.           Realizes
that the Securities have not been registered for sale under the Act or
applicable state securities laws (the “State Laws”) and may
be sold only pursuant to registration under the Act (including Regulation S, if
applicable) and State Laws, or an opinion of counsel satisfactory to counsel for
the Company that such registration is not required.

     

    G.           Acknowledges
that no federal or state agency, including the Securities and Exchange
Commission (the “SEC”) or the
securities commission or authority of any state, has approved or disapproved the
Securities, passed upon or endorsed the merits of the Offering of the Securities
or the accuracy or adequacy of the Disclosure Documents, or made any finding or
determination as to the fairness or fitness of the Securities for public
sale.

     

    H.           Believes
that the investment in the Securities is suitable for the undersigned based upon
the undersigned’s investment objectives and financial needs, and the undersigned
has adequate means to provide for the undersigned’s current financial needs and
personal/business contingencies and has no need for liquidity of investment with
respect to the Securities.

     

    I.           Is
experienced and knowledgeable in financial and business matters, capable of
evaluating the merits and risks of investing in the Securities, and does not
need or desire the assistance of a knowledgeable representative to aid in the
evaluation of such risks (or, in the alternative, has a knowledgeable
representative who such investor intends to use in connection with a decision as
to whether to purchase the Securities and who together with such investor has
such knowledge and experience in financial and business matters that they are
together capable of evaluating the merits and risks of investing in the
Securities).

     

    J.           Has
relied upon the advice of the undersigned’s legal counsel and accountants or
other financial advisors with respect to tax and other considerations relating
to the purchase of Securities in the Offering.  The undersigned is not
relying upon the Company with respect to the economic considerations involved to
make an investment decision in the Securities.

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    K.           Acknowledges
that an investment in a private placement of securities, including the
Securities, is HIGHLY SPECULATIVE in nature.  Accordingly, such an
investment may not be appropriate for Individual Retirement Accounts or other
retirement-type accounts that have conservative investment
objectives.  If this investment is in fact purchased in a
retirement-type account, the undersigned represents and affirms that it
understands the risks of the investment and has decided that such risks are
consistent with the undersigned’s investment objectives for this
account.

     

    3.           Investment
Intent.  The undersigned has been advised that the Securities
have not been registered under the Act or the relevant State Laws but are being
offered, and will be offered and sold pursuant to exemptions from the Act and
State Laws, and that the Company’s reliance upon such exemptions is predicated
in part on the undersigned’s representations contained herein.  The
undersigned represents and warrants that the Securities are being purchased for
the undersigned’s own account and for long term investment and without the
intention of reselling or redistributing the Securities, that the undersigned
has made no agreement with others regarding any of the Securities, and that the
undersigned’s financial condition is such that it is not likely that it will be
necessary for the undersigned to dispose of any of the Securities in the
foreseeable future.  The undersigned is aware that (i) in the view of
the SEC, a purchase of securities with an intent to resell by reason of any
foreseeable specific contingency or anticipated change in market values, or any
change in the liquidation or settlement of any loan obtained for the acquisition
of any of the Securities and for which the Securities were or may be pledged as
security would represent an intent inconsistent with the investment
representations set forth above and (ii) the transferability of the Securities
is restricted.

     

    The
restrictions on transfer contained in this paragraph 3 shall be evidenced by a
legend placed on the certificate(s) representing the Securities containing
substantially the following language:

     

    “The
securities represented by this certificate have not been registered under either
the Securities Act of 1933 or applicable state securities laws and may not be
sold, transferred, assigned, offered, pledged or otherwise distributed for value
unless there is an effective registration statement under such Act and such laws
covering such securities, or the Company receives an opinion of counsel
acceptable to the Company stating that such sale, transfer, assignment, offer,
pledge or other distribution for value is exempt from the registration and
prospectus delivery requirements of such Act and such laws.”

     

    The
undersigned further represents and agrees that if, contrary to the undersigned’s
foregoing intentions, the undersigned should later desire to dispose of or
transfer any of the Securities in any manner, the undersigned shall not do so
without first obtaining (i) an opinion of counsel satisfactory to the Company
that such proposed disposition or transfer may be made lawfully without the
registration of such Securities pursuant to the Act and applicable State Laws,
or (ii) registration of such Securities (it being expressly understood that the
Company shall not have any obligation to register such Securities except as
specifically set forth herein).

     

    4.           Residence.  The
undersigned represents and warrants that the undersigned is a bona fide resident
of (or, if an entity, is organized or incorporated under the laws of, and is
domiciled in) the state indicated on page 7 of this Agreement and that the
Securities are being purchased by the undersigned in the undersigned’s name
solely for the undersigned’s own beneficial interest and not as nominee for, on
behalf of, for the beneficial interest transfer to, any other person, trust, or
organization (except as specifically set forth in this Agreement).

     

    Paragraph
5 is required in connection with the exemptions from the Act and state laws
being relied on by the Company with respect to the offer and sale of the
Securities.  All of such information will be kept confidential and
will be reviewed only by the Company and its counsel.  The undersigned
agrees to furnish any additional information which the Company or its legal
counsel deem necessary in order to verify the responses set forth
below.

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    5.            Accredited
Status.  The undersigned represents and warrants as follows
(check all that apply):

     

    
      	
               
      

            	
              ___

            	
              A.

            	
              The
      undersigned is an individual with a net worth, or a joint net worth
      together with his or her spouse, in excess of $1,000,000, excluding the
      value of the undersigned’s primary residence. (In calculating net worth,
      you may include equity in personal property and real estate (other than
      your primary residence), cash, short term investments, stock and
      securities.  Equity in personal property and real estate should
      be based on the fair market value of such property minus debt secured by
      such property.)

            

    

     

    
      	
               
      

            	
              ___

            	
              B.

            	
              The
      undersigned is an individual (not a partnership, corporation, etc.) with
      income in excess of $200,000 in each of the prior two years and reasonably
      expects an income in excess of $200,000 in the current
    year.

            

    

     

    
      	
               
      

            	
              ___

            	
              C.

            	
              The
      undersigned is an individual (not a partnership, corporation, etc.) who,
      with his or her spouse, had joint income in excess of $300,000 in each of
      the prior two years and reasonably expects joint income in excess of
      $300,000 in the current year.

            

    

     

    
      	
               
      

            	
              ___

            	
              D.

            	
              The
      undersigned is a director or executive officer of the
    Company.

            

    

     

    
      	
               
      

            	
              ___

            	
              E.

            	
              The
      undersigned, if other than an individual, is an entity all of whose equity
      owners meet one of the tests set forth in (a) through (d) above (if
      relying on this category alone, each equity owner must complete a separate
      copy of this Agreement).

            

    

     

    
      	
               
      

            	
              ___

            	
              F.

            	
              The
      undersigned is an entity, and is an “Accredited
      Investor” as defined in Rule 501(a) of Regulation D under the
      Act.  This representation is based on the following (check one
      or more, as applicable):

            

    

     

    
      	
               
      

            	
              ___

            	
              1.

            	
              The
      undersigned (or, in the case of a trust, the undersigned trustee) is a
      bank or savings and loan association as defined in Sections (a)(2) and
      3(a)(5)(A), respectively, of the Act acting either in its individual or
      fiduciary capacity.

            

    

     

    
      	
               
      

            	
              ___

            	
              2.

            	
              The
      undersigned is an insurance company as defined in Section 2(13) of the
      Act.

            

    

     

    
      	
               
      

            	
              ___

            	
              3.

            	
              The
      undersigned is an investment company registered under the Investment
      Company Act of 1940 or a business development company as defined in
      Section 2(a)(48) of that Act.

            

    

     

    
      	
               
      

            	
              ___

            	
              4.

            	
              The
      undersigned is a Small Business Investment Company licensed by the U.S.
      Small Business Administration under Section 301(c) or (d) of the Small
      Business Investment Act of 1958.

            

    

     

    
      	
               
      

            	
              ___

            	
              5.

            	
              The
      undersigned is an employee benefit plan within the meaning of Title I
      of the Employee Retirement Income Security Act of 1974 (“ERISA”) and
      either (check all that apply):

            

    

     

    
      	
               
      

            	
              ___

            	
              a.

            	
              the
      investment decision is made by a plan fiduciary, as defined in Section
      3(21) of ERISA, which is either a bank, savings and loan association,
      insurance company, or registered investment adviser;
  or

            

    

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              ___

            	
              b.

            	
              the
      plan has total assets in excess of $5,000,000;
  or

            

    

     

    
      	
               
      

            	
              ___

            	
              c.

            	
              the
      plan is a self directed plan with investment decisions made solely by
      persons who are “Accredited Investors” as defined under the
      Act.

            

    

     

    
      	
               
      

            	
              ___

            	
              6.

            	
              The
      undersigned is a private business development company as defined in
      Section 202(a)(22) of the Investment Advisers Act of
  1940.

            

    

     

    
      	
               
      

            	
              ___

            	
              7.

            	
              The
      undersigned has total assets in excess of $5,000,000, was not formed for
      the specific purpose of acquiring shares of the Company and is one or more
      of the following (check one or more, as
  appropriate):

            

    

     

    
      	
               
      

            	
              ___

            	
              a.

            	
              an
      organization described in Section 501(c)(3) of the Internal Revenue Code;
      or

            

    

     

    
      	
               
      

            	
              ___

            	
              b.

            	
              a
      corporation; or

            

    

     

    
      	
               
      

            	
              ___

            	
              c.

            	
              a
      Massachusetts or similar business trust;
or

            

    

     

    
      	
               
      

            	
              ___

            	
              d.

            	
              a
      partnership.

            

    

     

    
      	
               
      

            	
              ___

            	
              8.

            	
              The
      undersigned is a trust with total assets exceeding $5,000,000 which was
      not formed for the specific purpose of acquiring shares of the Company and
      whose purchase is directed by a person who has such knowledge and
      experience in financial and business matters that he is capable of
      evaluating the merits and risks of the investment in the
      Securities.

            

    

     

    
      	
               
      

            	
              ___

            	
              9.

            	
              The
      undersigned is not an accredited
investor.

            

    

     

    6.       FINRA
Affiliation.  The undersigned is affiliated or associated,
directly or indirectly, with a Financial Industry Regulatory Authority (“FINRA”) member firm
or person.

     

    Yes  ̈                                 No  ̈

     

    If yes,
list the affiliated member firm or person:                                                                                                 

     

    Your
relationship to such member firm or
person:                                                                                                       

     

    7.       Entities.  If
the undersigned is not an individual but an entity, the individual signing on
behalf of such entity and the entity jointly and severally agree and certify
that:

     

    A.          The
undersigned was not organized for the specific purpose of acquiring the
Securities; and

     

    B.         
This Agreement has been duly authorized by all necessary action on the part of
the undersigned, has been duly executed by an authorized officer or
representative of the undersigned, and is a legal, valid and binding obligation
of the undersigned enforceable in accordance with its terms.

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    8.           Legal
Age.  If the undersigned is an individual, the undersigned is
of legal age.

     

    9.           Miscellaneous.

     

    A.           Manner
in which title is to be held: (check one):

     

    ___
Individual Ownership

     

    ___ Joint
Tenants with Right of Survivorship*

     

    ___
Partnership*

     

    ___
Tenants in Common*

     

    ___
Corporation

     

    ___
Trust

     

    ___ Other
(describe): _________________________________________

     

    *  Multiple
signatures required.

     

    B.           The
undersigned agrees that the undersigned understands the meaning and legal
consequences of the agreements, representations and warranties contained herein,
agrees that such agreements, representations and warranties shall survive and
remain in full force and effect after the execution hereof and payment for the
Securities, and further agrees to indemnify and hold harmless the Company, each
current and future officer, director, employee, agent and shareholder from and
against any and all loss, damage or liability due to, or arising out of, a
breach of any agreement, representation or warranty of the undersigned contained
herein.

     

    C.           This
Agreement shall be construed and interpreted in accordance with Minnesota law
without regard to conflict of law provisions.

     

    D.           The
undersigned agrees to furnish to the Company, upon request, such additional
information as may be deemed necessary to determine the undersigned’s
suitability as an investor.

     

    Signature
Page to Follow

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