Nevada
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000-50071
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90-0175540
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(State or other jurisdiction
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(Commission
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(IRS Employer
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of incorporation)
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File Number)
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Identification No.)
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Item 9.01
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Financial Statements and Exhibits
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(d)
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Exhibits
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10.1
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1.
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This Subscription form
is for use by United States accredited investors.
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2.
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COMPLETE
the information on page 2 of this Subscription Agreement.
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3.
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COMPLETE
the Questionnaire attached on pages 5 and 6 to this Subscription Agreement (the “Questionnaire”).
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4
.
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You may wire the total purchase price to the lawyers of Liberty Star Uranium & Metals Corp. pursuant to the wiring instructions previously provided. The lawyers
are authorized to immediately release the funds to the Issuer upon the Units being issued.
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5.
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All other information must be filled in where appropriate.
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TO:
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Liberty Star Uranium & Metals Corp. (the “
Issuer
”), of 5610 E Sutler Lane, Tucson, Arizona 85712
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________ Units
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US$ 0.0264
per Unit
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The Subscriber or the Beneficial Purchaser owns, directly or indirectly, the following securities of the Issuer:
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REGISTRATION INSTRUCTIONS
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DELIVERY INSTRUCTIONS
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Name to appear on certificate
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Name and account reference, if applicable
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Account reference if applicable
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Contact name
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Address
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Address
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Telephone Number
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EXECUTION BY SUBSCRIBER:
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DETAILS OF BENEFICIAL PURCHASER
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X
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(IF NOT THE SAME AS SUBSCRIBER)
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Signature of individual (if Subscriber
is
an individual)
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X
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Authorized signatory (if Subscriber
is not
an individual)
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Name of Beneficial Purchaser
(please print)
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Name of Subscriber (
please print
)
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Address of Beneficial Purchaser (residence)
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Name of authorized signatory (
please print
)
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Telephone Number of Beneficial Purchaser
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Address of Subscriber
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E-mail address of Beneficial Purchaser
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Telephone Number of Subscriber
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Accepted this day of ___________, 2011
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LIBERTY STAR URANIUM & METALS CORP.
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||
E-mail address of Subscriber
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Per:
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Social Security/Tax I.D. No. of Subscriber
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Authorized Signatory
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Reference date of this Subscription Agreement
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December 13, 2011 (the “
Agreement Date
”).
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The Issuer
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Liberty Star Uranium & Metals Corp.
(the “
Issuer
”)
.
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Offering
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The offering consists of up to $_____________ in value of Units (“
Units
”) of the Issuer. Each Unit consists of one share (
“Share”
) of common stock (
“Common Stock”
) of the Issuer and one warrant (
“Warrant”
) of the Issuer.
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Warrants
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Each Warrant may be exercised for 36 months following the Closing Date for one Share (a “
Warrant Share
”) at an exercise price of US$0.03696. The Warrants are non-transferrable.
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Issue Price
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US $0.0264 per Unit.
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Total Amount
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Up to US $______________ from the sale of Units.
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Selling Jurisdictions
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The Units may be sold in jurisdictions where they may be lawfully sold (the “
Selling Jurisdictions
”).
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Exemptions
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The offering will be made in accordance with the following exemptions:
(a)the Accredited Investor exemption as provided by Regulation D promulgated under the 1933 Act; and
(b)such other exemptions as may be available the securities laws of the Selling Jurisdictions.
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Registration of Securities
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The Shares and Warrants will not be registered with the United States Securities and Exchange Commission and will be tradable in compliance with Rule 144 restricted periods.
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Resale restrictions and legends
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The Subscriber acknowledges that any resale of any of the Securities will be subject to resale restrictions contained in the securities legislation applicable to the Subscriber or proposed transferee. The Subscriber acknowledges that none of the Securities have been registered under the 1933 Act or the securities laws of any state of the United States. The Securities may not be offered or sold in the United States unless registered in accordance with federal securities laws and all applicable state securities laws or exemptions from such registration requirements are available.
The Subscriber acknowledges that the certificates representing the Shares and the Warrant Shares will bear the following legends:
“THESE SECURITIES HAVE NOT BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.”
The Subscriber acknowledges that the certificate(s) representing the Warrants will bear the following legends:
“THESE WARRANTS AND THE SECURITIES THAT MAY BE ISSUED UPON THE EXERCISE OF THESE WARRANTS HAVE NOT BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.”
The Subscriber and any Beneficial Purchaser are advised to consult with their own legal counsel or advisors to determine the resale restrictions that may be applicable to them.
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Closing Date
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The completion of the sale and purchase of the Units will take place in one or more closings, on a date or dates as agreed to by the Issuer and the Subscriber. Payment for, and delivery of the Units, is scheduled to occur on or about December 13, 2011 or such later date as may be agreed upon by the Issuer and the Subscriber (the “
Closing Date
”).
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Jurisdiction of organization
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The Issuer is incorporated under the laws of the State of Nevada.
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Market
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Certain market makers make market in the Issuer’s shares of common stock on the Financial Industry Regulatory Authority’s OTC Bulletin Board.
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Commissions with Jurisdiction Over the Issuer
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The “
Commissions with Jurisdiction Over the Issuer
” is the United States Securities and Exchange Commission and any applicable state securities regulators.
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The “
Securities Legislation Applicable to the Issuer
” is the U.S. Securities Act of 1933, U.S. Securities Exchange Act of 1934, and any applicable state securities laws.
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_____
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Category 1
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An organization described in Section 501(c)(3) of the United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the specific purpose of acquiring the Securities, with total assets in excess of US $5,000,000.
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_____
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Category 2
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A natural person whose individual net worth, or joint net worth with that person’s spouse, on the date of purchase exceeds US$1,000,000 excluding the value of the primary residence of such person(s) and the related amount of indebtedness secured by the primary residence up to its fair market value.
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_____
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Category 3
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A natural person who had an individual income in excess of US$200,000 in each of the two most recent years or joint income with that person’s spouse in excess of US$300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
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_____
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Category 4
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A “bank” as defined under Section (3)(a)(2) of the 1933 Act or savings and loan association or other institution as defined in Section 3(a)(5)(A) of the 1933 Act acting in its individual or fiduciary capacity; a broker dealer registered pursuant to Section 15 of the
Securities Exchange Act of 1934
(United States); an insurance company as defined in Section 2(13) of the 1933 Act; an investment company registered under the
Investment Company Act of 1940
(United States) or a business development company as defined in Section 2(a)(48) of such Act; 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
(United States); a plan with total assets in excess of $5,000,000 established and maintained by a state, a political subdivision thereof, or an agency or instrumentality of a state or a political subdivision thereof, for the benefit of its employees; an employee benefit plan within the meaning of the
Employee Retirement Income Security Act of 1974
(United States) whose investment decisions are made by a plan fiduciary, as defined in Section 3(21) of such Act, which is either a bank, savings and loan association, insurance company or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000, or, if a self-directed plan, whose investment decisions are made solely by persons that are accredited investors.
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_____
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Category 5
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A private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940
(United States).
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_____
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Category 6
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A director or executive officer of the Issuer.
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_____
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Category 7
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A trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Securities, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) under the 1933 Act.
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_____
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Category 8
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An entity in which all of the equity owners satisfy the requirements of Category 2 or 3.
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If a Corporation, Partnership or Other Entity:
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If an Individual:
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__________________________________________
Print of Type Name of Entity
__________________________________________
Signature of Authorized Signatory
__________________________________________
Type of Entity
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_______________________________________
Signature
_______________________________________
Print or Type Name
_______________________________________
Social Security/Tax I.D. No.
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1.
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DEFINITIONS
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(a)
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“
1933 Act
” means the United States Securities Act of 1933, as amended;
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(b)
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“
Applicable
Legislation
” means the Securities Legislation Applicable to the Issuer (as defined on page 4) and all legislation incorporated in the definition of this term in other parts of the Subscription Agreement, together with the regulations and rules made and promulgated under that legislation and all administrative policy statements, blanket orders and rulings, notices and other administrative directions issued by the Commissions;
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(c)
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“Beneficial Purchaser”
means a person for whom the Subscriber is acting in purchasing the Units who will be the beneficial owner of the Securities within the meaning attributed to it by Rule 13d-3 adopted by the SEC under the 1934 Act;
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(d)
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“
Closing
” means the completion of the sale and purchase of the Units;
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(e)
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“
Closing Date
” has the meaning assigned in the Terms;
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(f)
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“
Commissions
” means the Commissions with Jurisdiction over the Issuer (as defined on page 4) and the securities commissions incorporated in the definition of this term in other parts of the Subscription Agreement;
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(g)
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“
General Provisions
” means those portions of the Subscription Agreement headed “
General Provision
s” and contained on pages 7 to 13;
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(h)
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“
Private Placement
” means the offering of the Securities on the terms and conditions of this Subscription Agreement;
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(i)
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“
Securities
” means the Shares, the Warrants and the Warrant Shares, as defined in the Terms;
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(j)
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“
Subscription
Agreement
” means the first (cover) page, the Terms on pages 3 to 4, the General Provisions on pages 7 to 13 and the other schedules and appendices incorporated by reference; and
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(k)
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“
Terms
” means those portions of the Subscription Agreement headed “Terms” and contained on pages 3 to 4.
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(a)
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the Securities have not been registered under the 1933 Act, or under any state securities or “blue sky” laws of any state of the United States, and are being offered only in a transaction not involving any public offering within the meaning of the 1933 Act, and, unless so registered, may not be offered or sold in the United States or to U.S. Persons, except pursuant to an effective registration statement under the 1933 Act, or pursuant to an exemption from, or in a transaction not subject to, the registration requirements of the 1933 Act, and in each case only in accordance with Applicable Legislation;
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(b)
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the Issuer will refuse to register any transfer of the Securities not made in accordance with the provisions of Regulation S, pursuant to an effective registration statement under the 1933 Act or pursuant to an available exemption from, or in a transaction not subject to, the registration requirements of the 1933 Act;
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(c)
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the Issuer has not undertaken, and will have no obligation, to register any of the Securities under the 1933 Act;
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(d)
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the Subscriber and the Subscriber’s advisor(s) have had a reasonable opportunity to ask questions of and receive answers from the Issuer regarding the Offering, and to obtain additional information, to the extent possessed or obtainable without unreasonable effort or expense, necessary to verify the accuracy of the information contained in the public information which has been filed by the Issuer with the U.S. Securities and Exchange Commission, or any business plan, corporate profile or any other document provided to the Subscriber;
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(e)
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the books and records of the Issuer are available upon reasonable notice for inspection, subject to certain confidentiality restrictions, by the Subscriber during reasonable business hours at its principal place of business and that all documents, records and books pertaining to this Offering have been made available for inspection by the Subscriber, the Subscriber’s attorney and/or advisor(s);
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(f)
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by execution hereof the Subscriber has waived the need for the Issuer to communicate its acceptance of the purchase of the Securities pursuant to this Subscription Agreement;
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(g)
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the Issuer is entitled to rely on the representations and warranties and the statements and answers of the Subscriber contained in this Subscription Agreement and in the Questionnaire, and the Subscriber will hold harmless the Issuer from any loss or damage it may suffer as a result of the Subscriber’s failure to correctly complete this Subscription Agreement or the Questionnaire;
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(h)
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the Subscriber shall indemnify and hold harmless the Issuer and, where applicable, its respective directors, officers, employees, agents, advisors and shareholders from and against any and all loss, liability, claim, damage and expense whatsoever (including, but not limited to, any and all fees, costs and expenses whatsoever reasonably incurred in investigating, preparing or defending against any claim, lawsuit, administrative proceeding or investigation whether commenced or threatened) arising out of or based upon any representation or warranty of the Subscriber contained herein, the Questionnaire or in any other document furnished by the Subscriber to the Issuer in connection herewith, being untrue in any material respect or any breach or failure by the Subscriber to comply with any covenant or agreement made by the Subscriber to the Issuer in connection therewith;
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(i)
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the issuance and sale of the Securities to the Subscriber will not be completed if it would be unlawful or if, in the discretion of the Issuer acting reasonably, it is not in the best interests of the Issuer;
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(j)
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the Subscriber has been advised to consult its own legal, tax and other advisors with respect to the merits and risks of an investment in the Securities and with respect to applicable resale restrictions and it is solely responsible (and the Issuer is not in any way responsible) for compliance with applicable resale restrictions;
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(k)
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the Securities are not listed on any stock exchange or automated dealer quotation system and no representation has been made to the Subscriber that any of the Securities will become listed on any stock exchange or automated dealer quotation system, except that currently certain market makers make market in shares of common stock the Issuer on the Financial Industry Regulatory Authority’s OTC Bulletin Board;
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(l)
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neither the Commissions or similar regulatory authority has reviewed or passed on the merits of the Securities;
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(m)
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no documents in connection with this Offering have been reviewed by the SEC or any state securities administrators;
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(n)
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there is no government or other insurance covering any of the Securities; and
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(o)
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this Subscription Agreement is not enforceable by the Subscriber unless it has been accepted by the Issuer, and the Subscriber acknowledges and agrees that the Issuer reserves the right to reject any subscription for any reason.
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(a)
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the Subscriber and any Beneficial Purchaser are U.S. Persons;
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(b)
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the Subscriber has received and carefully read this Subscription Agreement;
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(c)
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the Subscriber has the legal capacity and competence to enter into and execute this Subscription Agreement and to take all actions required pursuant hereto and, if the Subscriber is an entity, it is duly incorporated or organized and validly subsisting under the laws of its jurisdiction of incorporation or organization and all necessary approvals by its directors, shareholders and others have been obtained to authorize execution and performance of this Subscription Agreement on behalf of the Subscriber;
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(d)
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the Subscriber and any Beneficial Purchaser (i) have adequate net worth and means of providing for their current financial needs and possible personal contingencies, (ii) has no need for liquidity in this investment, and (iii) are able to bear the economic risks of an investment in the Securities for an indefinite period of time, and can afford the complete loss of such investment;
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(e)
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the Subscriber and any Beneficial Purchaser are aware that an investment in the Issuer is speculative and involves certain risks, including the possible loss of the investment;
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(f)
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the decision to execute this Subscription Agreement and purchase the Securities agreed to be purchased hereunder has not been based upon any oral or written representation as to fact or
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(g)
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otherwise made by or on behalf of the Issuer and such decision is based entirely upon a review of any public information which has been filed by the Issuer with the U.S. Securities and Exchange Commission in compliance, or intended compliance, with applicable securities legislation;
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(h)
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the entering into of this Subscription Agreement and the transactions contemplated hereby do not result in the violation of any of the terms and provisions of any law applicable to, or, if applicable, the constating documents of, the Subscriber, or of any agreement, written or oral, to which the Subscriber may be a party or by which the Subscriber is or may be bound;
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(i)
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the Subscriber has duly executed and delivered this Subscription Agreement and it constitutes a valid and binding agreement of the Subscriber enforceable against the Subscriber;
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(j)
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the Subscriber and any Beneficial Purchaser have the requisite knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of the investment in the Securities and the Issuer, and the Subscriber is providing evidence of such knowledge and experience in these matters through the information requested in the Questionnaire;
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(k)
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the Subscriber understands and agrees that the Issuer and others will rely upon the truth and accuracy of the acknowledgements, representations and agreements contained in this Subscription Agreement, and agrees that if any of such acknowledgements, representations and agreements are no longer accurate or have been breached, the Subscriber shall promptly notify the Issuer;
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(l)
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all information contained in the Questionnaire is complete and accurate and may be relied upon by the Issuer, and the Subscriber will notify the Issuer immediately of any material change in any such information occurring prior to the closing of the purchase of the Securities;
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(m)
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Except for any Beneficial Purchaser disclosed on page 2 of this Subscription Agreement, the Subscriber is purchasing the Securities for its own account for investment purposes only and not for the account of any other person and not for distribution, assignment or resale to others, and no other person has a direct or indirect beneficial interest in such Securities, and the Subscriber has not subdivided its interest in the Securities with any other person;
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(n)
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the Subscriber is not an underwriter of, or dealer in, the shares of common stock of the Issuer, nor is the Subscriber participating, pursuant to a contractual agreement or otherwise, in the distribution of the Securities;
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(o)
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the Subscriber understands and agrees that none of the Securities have been registered under the 1933 Act, or under any state securities or “blue sky” laws of any state of the United States, and, unless so registered, may not be offered or sold in the United States or, directly or indirectly, to U.S. Persons except in accordance with the provisions of Regulation S, pursuant to an effective registration statement under the 1933 Act, or pursuant to an exemption from, or in a transaction not subject to, the registration requirements of the 1933 Act and in each case only in accordance with applicable state securities laws;
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(p)
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the Subscriber understands and agrees that the Issuer will refuse to register any transfer of the Securities not made in accordance with the provisions of Regulation S, pursuant to an effective registration statement under the 1933Act or pursuant to an available exemption from the registration requirements of the 1933 Act;
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(q)
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the Subscriber has made an independent examination and investigation of an investment in the Securities and the Issuer and has depended on the advice of its legal and financial advisors and agrees that the Issuer will not be responsible in any way whatsoever for the Subscriber’s decision to invest in the Securities of the Issuer;
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(r)
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if the Subscriber is acquiring the Securities as a fiduciary or agent for one or more investor accounts, the investor accounts for which the Subscriber acts as a fiduciary or agent satisfy the definition of an “Accredited Investor”, as the term is defined under Regulation D of the 1933 Act;
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(s)
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if the Subscriber is acquiring the Securities as a fiduciary or agent for one or more investor accounts, the Subscriber has sole investment discretion with respect to each such account, and the Subscriber has full power to make the foregoing acknowledgements, representations and agreements on behalf of such account;
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(t)
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the Subscriber and any Beneficial Purchaser are not aware of any advertisement of any of the Securities and is not acquiring the Securities as a result of any form of general solicitation or general advertising including advertisements, articles, notices or other communications published in any newspaper, magazine or similar media or broadcast over radio or television, or any seminar or meeting whose attendees have been invited by general solicitation or general advertising; and
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(u)
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no person has made to the Subscriber or any Beneficial Purchaser any written or oral representations:
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(i)
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that any person will resell or repurchase any of the Securities;
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(ii)
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that any person will refund the purchase price of any of the Securities;
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(iii)
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as to the future price or value of any of the Securities; or
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(iv)
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that any of the Securities will be listed and posted for trading on any stock exchange or automated dealer quotation system or that application has been made to list and post any of the Securities of the Issuer on any stock exchange or automated dealer quotation system, except that currently certain market makers make market in shares of common stock of the Issuer on the Financial Industry Regulatory Authority’s OTC Bulletin Board.
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