Nevada
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000-55049
|
27-3098487
|
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(State or other jurisdiction
|
(Commission
|
(IRS Employer
|
||
of incorporation)
|
File Number)
|
Identification No.)
|
/s/ Bruce Elliott
|
|
Bruce Elliott
|
|
President
|
|
October 31, 2017
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1. |
You must complete all the information in the boxes on page 2 and sign where indicated with an “
X
”.
|
2. |
If you are resident in Canada, you must complete and sign Exhibit A “Canadian Investor Questionnaire” that starts on page 13. The purpose of this form is to determine whether you meet the standards for participation in a private placement under applicable Canadian securities laws. In order for the Issuer to satisfy its obligations under applicable Canadian securities laws, you may be required to provide additional evidence to verify the information you have provided in Exhibit A “Canadian Investor Questionnaire” that starts on page 13.
|
3. |
If you are a “U.S. Purchaser”, as defined in Exhibit B, you must complete and sign Exhibit B “United States Accredited Investor Questionnaire” that starts on page 23
.
|
Subscriber Information
____________________________________________________________________
|
Note to be Purchased
Principal Amount of Note: $_________________________________________________________
(the “
Principal Amount
” or the
“
Subscription Amount
”)
|
|
(Name of Subscriber)
|
||
Account Reference (if applicable): __________________________________________
|
||
X____________________________________________________________________
|
||
(Signature of Subscriber – if the Subscriber is an Individual)
|
||
X____________________________________________________________________
|
||
(Signature of Authorized Signatory – if the Subscriber is not an Individual)
____________________________________________________________________
(Name and Title of Authorized Signatory – if the Subscriber is not an Individual)
____________________________________________________________________
(SIN, SSN, or other Tax Identification Number of the Subscriber)
____________________________________________________________________
(Subscriber’s Address, including City and Postal Code)
____________________________________________________________________
____________________________________________________________________
(Telephone Number)_________________________________
(Email Address)__________________________
|
||
Register the Note as set forth below
:
____________________________________________________________________
(Name to Appear on Note Certificate)
____________________________________________________________________
(Account Reference, if applicable)
____________________________________________________________________
(Address, including Postal Code)
|
Address: |
AppCoin Innovations Inc.
3250 Oakland Hills Court Fairfield, CA 94534 USA |
Email: |
jgeiskopf@aol.com
|
Attention: |
James P. Geiskopf
|
(a)
|
this Agreement;
|
(b)
|
if the Subscribers is a resident of Canada, the Canadian Investor Questionnaire (the “
Canadian Questionnaire
”) attached as Exhibit A that starts on page , along with any additional evidence that may be requested by the Issuer to verify the information provided in the Canadian Questionnaire;
|
(c)
|
if the Subscriber is a U.S. Purchaser (as defined in Exhibit B), the United States Accredited Investor Questionnaire (the “
U.S. Questionnaire
” and, together with the Canadian Questionnaire, the “
Questionnaires
”) attached as Exhibit B that starts on page ; and
|
(d)
|
such other supporting documentation that the Issuer or counsel of the Issuer (the “
Issuer’s Counsel
”) may request to establish the Subscriber’s qualification as a qualified investor,
|
(e)
|
and the Subscriber acknowledges and agrees that the Issuer will not consider the Subscription for acceptance unless the Subscriber has provided all of such documents to the Issuer.
|
(a)
|
the Issuer having obtained all necessary approvals and consents, including regulatory approvals for the Offering; and
|
(b)
|
the issue and sale of the Note being exempt from the requirement to file a prospectus and the requirement to deliver an offering memorandum under applicable securities laws relating to the sale of the Notes, or the Issuer having received such orders, consents or approvals as may be required to permit such sale without the requirement to file a prospectus or deliver an offering memorandum.
|
(a)
|
none of the Securities have been or will be registered under the United States
Securities Act of 1933
, as amended, (the “
1933 Act
”), or under any 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 any U.S. Person (as defined in Section 6.2), except in accordance with the provisions of Regulation S under the 1933 Act (“
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, provincial and foreign securities laws;
|
(b)
|
the Issuer has not undertaken, and will have no obligation, to register any of the Securities under the 1933 Act or any other applicable securities laws;
|
(c)
|
the Issuer will refuse to register the transfer of any of the Securities to a U.S. Person not made pursuant to an effective registration statement under the 1933 Act or pursuant to an available exemption from the registration requirements of the 1933 Act and in each case in accordance with applicable laws;
|
(d)
|
the decision to execute this Agreement and to acquire the Securities has not been based upon any oral or written representation as to fact or 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 United State Securities and Exchange Commission (collectively, the “
Public Record
”);
|
(e)
|
the Issuer and others will rely upon the truth and accuracy of the acknowledgements, representations, warranties, covenants and agreements of the Subscriber contained in this Agreement and the Questionnaires, as applicable, and agrees that if any of such acknowledgements, representations and agreements are no longer accurate or have been breached, the Subscriber will promptly notify the Issuer;
|
(f)
|
there are risks associated with the purchase of the Securities, as more fully described in the Issuer’s periodic disclosure forming part of the Public Record;
|
(g)
|
the Subscriber and the Subscriber’s advisor(s) have had a reasonable opportunity to ask questions of and receive answers from the Issuer in connection with the distribution of the Securities hereunder, and to obtain additional information, to the extent possessed or obtainable without unreasonable effort or expense, necessary to verify the accuracy of the information about the Issuer;
|
(h)
|
a portion of this Offering may be sold pursuant to an agreement between the Issuer and one or more agents registered in accordance with applicable securities laws, in which case the Issuer will pay a fee and/or compensation securities on terms as set out in such agency agreement;
|
(i)
|
finder’s fees or broker’s commissions may be payable by the Issuer to finders who introduce subscribers to the Issuer;
|
(j)
|
the books and records of the Issuer were 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 all documents, records and books in connection with the distribution of the Securities hereunder have been made available for inspection by the Subscriber, the Subscriber’s legal counsel and/or its advisor(s);
|
(k)
|
all of the information which the Subscriber has provided to the Issuer is correct and complete and if there should be any change in such information prior to the Closing, the Subscriber will immediately notify the Issuer, in writing, with the details of any such change;
|
(l)
|
the Issuer is entitled to rely on the representations and warranties of the Subscriber contained in this Agreement and the Questionnaires, as applicable, and the Subscriber will hold harmless the Issuer from any loss or damage it or they may suffer as a result of the Subscriber’s failure to correctly complete this Agreement or the Questionnaires, as applicable;
|
(m)
|
any resale of the Securities by the Subscriber will be subject to resale restrictions contained in the securities laws applicable to the Issuer, the Subscriber and any proposed transferee and it is the responsibility of the Subscriber to find out what those restrictions are and to comply with such restrictions before selling any of the Securities;
|
(n)
|
the Subscriber has been advised to consult the Subscriber’s 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:
|
(i)
|
any applicable laws of the jurisdiction in which the Subscriber is resident in connection with the distribution of the Securities hereunder, and
|
(ii)
|
applicable resale restrictions;
|
(o)
|
there may be material tax consequences to the Subscriber of an acquisition or disposition of the Securities and the Issuer gives no opinion and makes no representation to the Subscriber with respect to the tax consequences to the Subscriber under federal, state, provincial, local or foreign tax laws that may apply to the Subscriber’s acquisition or disposition of the Securities;
|
(p)
|
the Subscriber consents to the placement of a legend or legends on any certificate or other document evidencing any of the Securities setting forth or referring to the restrictions on transferability and sale thereof contained in this Agreement;
|
(q)
|
the Issuer has advised the Subscriber that the Issuer is relying on an exemption from the requirements to provide the Subscriber with a prospectus and to sell the Securities through a person registered to sell securities under provincial securities laws and other applicable securities laws, and, as a consequence of acquiring the Securities pursuant to such exemption, certain protections, rights and remedies provided by applicable securities laws (including the various provincial securities acts), including statutory rights of rescission or damages, will not be available to the Subscriber;
|
(r)
|
no securities commission or similar regulatory authority has reviewed or passed on the merits of any of the Securities;
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(s)
|
there is no government or other insurance covering any of the Securities; and
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(t)
|
this Agreement is not enforceable by the Subscriber unless it has been accepted by the Issuer, and the Issuer reserves the right to reject this Subscription for any reason.
|
(a)
|
unless the Subscriber has completed Exhibit B, the Subscriber is not a U.S. Person;
|
(b)
|
the Subscriber is resident in the jurisdiction set out on page 2 of this Agreement;
|
(c)
|
if the Subscriber is resident outside of Canada:
|
(i)
|
the Subscriber is knowledgeable of, or has been independently advised as to, the applicable securities laws having application in the jurisdiction in which the Subscriber is resident (the “
International Jurisdiction
”) which would apply to the offer and sale of the Securities,
|
(ii)
|
the Subscriber is purchasing the Securities pursuant to exemptions from prospectus or equivalent requirements under applicable securities laws or, if such is not applicable, the Subscriber is permitted to purchase the Securities under the applicable laws of the International Jurisdiction without the need to rely on any exemptions,
|
(iii)
|
the applicable laws of the authorities in the International Jurisdiction do not require the Issuer to make any filings or seek any approvals of any kind whatsoever from any securities regulator of any kind whatsoever in the International Jurisdiction in connection with the offer, issue, sale or resale of any of the Securities,
|
(iv)
|
the purchase of the Securities by the Subscriber does not trigger:
|
A.
|
any obligation to prepare and file a prospectus or similar document, or any other report with respect to such purchase in the International Jurisdiction, or
|
B.
|
any continuous disclosure reporting obligation of the Issuer in the International Jurisdiction, and
|
(v)
|
the Subscriber will, if requested by the Issuer, deliver to the Issuer a certificate or opinion of local counsel from the International Jurisdiction which will confirm the matters referred to in subparagraphs (ii), (iii) and (iv) above to the satisfaction of the Issuer, acting reasonably;
|
(d)
|
the Subscriber has the legal capacity and competence to enter into and execute this Agreement and to take all actions required pursuant hereto and, if the Subscriber is a corporate entity, it is duly incorporated and validly subsisting under the laws of its jurisdiction of incorporation and all necessary approvals by its directors, shareholders and others have been obtained to authorize execution and performance of this Agreement on behalf of the Subscriber;
|
(e)
|
the entering into of this 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;
|
(f)
|
the Subscriber has duly executed and delivered this Agreement and it constitutes a valid and binding agreement of the Subscriber enforceable against the Subscriber;
|
(g)
|
the Subscriber has received and carefully read this Agreement;
|
(h)
|
the Subscriber is aware that an investment in the Issuer is speculative and involves certain risks (including those risks disclosed in the Public Record), including the possible loss of the entire investment;
|
(i)
|
the Subscriber has made an independent examination and investigation of an investment in the Securities and the Issuer and agrees that the Issuer will not be responsible in any way for the Subscriber’s decision to invest in the Securities and the Issuer;
|
(j)
|
the Subscriber is not an underwriter of, or dealer in, any of the Securities, nor is the Subscriber participating, pursuant to a contractual agreement or otherwise, in the distribution of the Securities;
|
(k)
|
the Subscriber is 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
|
(l)
|
no person has made to the Subscriber any written or oral representations:
|
(i)
|
that any person will resell or repurchase any of the Securities,
|
(ii)
|
that any person will refund the purchase price of any of the Securities, or
|
(iii)
|
as to the future price or value of any of the Securities.
|
(a)
|
the Issuer may deliver to any securities commission having jurisdiction over the Issuer, the Subscriber or this Subscription, including any Canadian provincial securities commissions, the United States Securities and Exchange Commission and/or any state securities commissions (collectively, the “
Commissions
”), certain personal information pertaining to the Subscriber, including the Subscriber’s full name, residential address and telephone number, the number of securities of the Issuer owned by the Subscriber, the number of Securities purchased by the Subscriber, the total Subscription Amount paid, the prospectus exemption relied on by the Issuer and the date of distribution of the Notes;
|
(b)
|
such information is being collected indirectly by the Commissions under the authority granted to them in applicable securities laws;
|
(c)
|
such information is being collected for the purposes of the administration and enforcement of applicable securities laws; and
|
(d)
|
the Subscriber may contact the following public official in Ontario with respect to questions about the Ontario Securities Commission’s indirect collection of such information at the following address and telephone number:
|
(e)
|
Administrative Assistant to the Director of Corporate Finance
Ontario Securities Commission Suite 1903, Box 55 20 Queen Street West Toronto, ON M5H 3S8 Telephone: (416) 593-8086 |
(i) |
is purchasing the Note as principal (or deemed principal under the terms of National Instrument 45-106 -
Prospectus Exemptions
adopted by the Canadian Securities Administrators (“
NI 45-106
”));
|
(ii) | (A) | is resident in or is subject to the laws of one of the following (check one): |
(B) |
☐
is resident in a country other than Canada or the United States; and
|
(iii) |
has not been provided with any offering memorandum in connection with the purchase of the Note.
|
I.
SUBSCRIBERS PURCHASING UNDER THE “ACCREDITED INVESTOR” EXEMPTION
|
|
(a)
|
the Subscriber is not a trust company or trust company registered under the laws of Prince Edward Island that is not registered or authorized under the
Trust and Loan Companies Act
(Canada) or under comparable legislation in another jurisdiction of Canada;
|
(b)
|
the Subscriber is an “accredited investor” within the meaning of NI 45-106, by virtue of satisfying the indicated criterion as set out in Appendix “A” to this certificate
(YOU MUST ALSO INITIAL OR PLACE A CHECK-MARK ON THE APPROPRIATE LINE IN APPENDIX “A” ATTACHED TO THIS CERTIFICATE)
|
(c)
|
If the Subscriber is an “accredited investor” within the meaning of NI 45-106 by virtue of satisfying the indicated criterion as set out in paragraphs (d), (f) or (g) of Appendix “A” to this certificate, the Subscriber has provided the Issuer with the signed risk acknowledgement form set out in Appendix “B” to this certificate;
|
II.
MINIMUM AMOUNT INVESTMENT
|
|
(a)
|
the Subscriber is not an individual as that term is defined in applicable Canadian securities laws.
|
(b)
|
the Subscriber is purchasing the Note as principal for its own account and not for the benefit of any other person;
|
(c)
|
the Note have an acquisition cost to the Subscriber of not less than $150,000, payable in cash at the Closing; and
|
(d)
|
the Subscriber was not created and is not being used solely to purchase or hold securities in reliance on the prospectus exemption provided under Section 2.10 of NI 45-106, it pre-existed the Offering and has a bona fide purpose other than investment in the Note.
|
(i) |
one of them is the subsidiary of the other, or
|
(ii) |
each of them is controlled by the same person;
|
(i) |
a person who holds a sufficient number of the voting rights attached to all outstanding voting securities of an issuer to affect materially the control of the issuer, or
|
(ii) |
each person in a combination of persons, acting in concert by virtue of an agreement, arrangement, commitment or understanding, which holds in total a sufficient number of the voting rights attached to all outstanding voting securities of an issuer to affect materially the control of the issuer,
|
(i) |
a member of the board of directors of a company or an individual who performs similar functions for a company, and
|
(ii) |
with respect to a person that is not a company, an individual who performs functions similar to those of a director of a company;
|
(i) |
a person that is registered as an investment dealer and authorized to give advice with respect to the type of security being distributed; and
|
(ii) |
in Saskatchewan or Manitoba, also means a lawyer who is a practicing member in good standing with a law society of a jurisdiction of Canada or a public accountant who is a member in good standing of an institute or association of chartered accountants, certified general accountants or certified management accountants in a jurisdiction of Canada provided that the lawyer or public accountant must not:
|
(A) |
have a professional, business or personal relationship with the issuer, or any of its directors, executive officers, founders or control persons, and
|
(B) |
have acted for or been retained personally or otherwise as an employee, executive officer, director, associate or partner of a person that has acted for or been retained by the issuer or any of its directors, executive officers, founders or control persons within the previous 12 months;
|
(i) |
a chair, vice-chair or president,
|
(ii) |
a vice-president in charge of a principal business unit, division or function including sales, finance or production, or
|
(iii) |
performing a policy-making function in respect of the issuer;
|
(i) |
cash,
|
(ii) |
securities, or
|
(iii) |
a contract of insurance, a deposit or an evidence of a deposit that is not a security for the purposes of securities legislation;
|
(g) |
“
foreign jurisdiction
” means a country other than Canada or a political subdivision of a country other than Canada;
|
(i) |
acting alone, in conjunction, or in concert with one or more persons, directly or indirectly, takes the initiative in founding, organizing or substantially reorganizing the business of the issuer, and
|
(ii) |
at the time of the distribution or trade is actively involved in the business of the issuer;
|
(i) |
“
fully managed account
” means an account of a client for which a person makes the investment decisions if that person has full discretion to trade in securities for the account without requiring the client’s express consent to a transaction;
|
(j) |
“
individual
” means a natural person, but does not include
|
(i) |
a partnership, unincorporated association, unincorporated syndicate, unincorporated organization or trust, or
|
(ii) |
a natural person in the person's capacity as a trustee, executor, administrator or personal or other legal representative;
|
(k) |
“
investment fund
” means a mutual fund or a non-redeemable investment fund, and, for great certainty in British Columbia, includes an employee venture capital corporation and a venture capital corporation as such terms are defined in National Instrument 81-106
Investment Fund Continuous Disclosure
;
|
(l) |
“
jurisdiction
” or “jurisdiction of Canada” means a province or territory of Canada except when used in the term foreign jurisdiction;
|
(m) |
“
non-redeemable investment fund
” means an issuer:
|
(A) |
for the purpose of exercising or seeking to exercise control of an issuer, other than an issuer that is a mutual fund or a non-redeemable investment fund, or
|
(B) |
for the purpose of being actively involved in the management of any issuer in which it invests, other than an issuer that is a mutual fund or a non-redeemable investment fund, and
|
(i) |
an individual;
|
(ii) |
a corporation;
|
(iii) |
a partnership, trust, fund and an association, syndicate, organization or other organized group of persons, whether incorporated or not; and
|
(iv) |
an individual or other person in that person’s capacity as a trustee, executor, administrator or personal or other legal representative;
|
(i) |
liabilities incurred or assumed for the purpose of financing the acquisition or ownership of financial assets, or
|
(ii) |
liabilities that are secured by financial assets; and
|
(i) |
is married to another individual and is not living separate and apart within the meaning of the
Divorce Act
(Canada), from the other individual,
|
(ii) |
is living with another individual in a marriage-like relationship, including a marriage-like relationship between individuals of the same gender, or
|
(iii) |
in Alberta, is an individual referred to in paragraph (i) or (ii), or is an adult interdependent partner within the meaning of the
Adult Interdependent Relationships Act
(Alberta).
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|
☐
|
(a)
|
except in Ontario, a person registered under the securities legislation of a jurisdiction of Canada as an adviser or dealer,
|
☐
|
(b)
|
an individual registered under the securities legislation of a jurisdiction of Canada as a representative of a person referred to in paragraph (a),
|
☐
|
(c)
|
an individual formerly registered under the securities legislation of a jurisdiction of Canada, other than an individual formerly registered solely as a representative of a limited market dealer under one or both of the
Securities Act
(Ontario) or the
Securities Act
(Newfoundland and Labrador),
|
☐
|
(d)
|
an individual who, either alone or with a spouse, beneficially owns financial assets having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $1,000,000
(YOU MUST INDICATE YOUR FINANCIAL ASSETS HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(e)
|
an individual who beneficially owns financial assets having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $5,000,000,
|
☐
|
(f)
|
an individual whose net income before taxes exceeded $200,000 in each of the 2 most recent calendar years or whose net income before taxes combined with that of a spouse exceeded $300,000 in each of the 2 most recent calendar years and who, in either case, reasonably expects to exceed that net income level in the current calendar year
(YOU MUST INDICATE YOUR NET INCOME HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(g)
|
an individual who, either alone or with a spouse, has net assets of at least $5,000,000
(YOU MUST INDICATE YOUR NET ASSETS HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(h)
|
a person, other than an individual or investment fund, that has net assets of at least $5,000,000 as shown on its most recently prepared financial statements
and that has not been created or used solely to purchase or hold securities as an accredited investor as defined in this paragraph (h),
|
☐
|
(i)
|
an investment fund that distributes or has distributed its securities only to
(i)
a person that is or was an accredited investor at the time of the distribution,
(ii)
a person that acquires or acquired securities in the circumstances referred to in sections 2.10 [Minimum amount investment] of NI 45-106, or 2.19 [Additional investment in investment funds] of NI 45-106, or
(iii)
a person described in paragraph (i) or (ii) that acquires or acquired securities under section 2.18 [Investment fund reinvestment] of NI 45-106,
|
☐
|
(j)
|
an investment fund that distributes or has distributed securities under a prospectus in a jurisdiction of Canada for which the regulator or, in Québec, the securities regulatory authority, has issued a receipt,
|
☐
|
(k)
|
a trust company or trust corporation registered or authorized to carry on business under the
Trust and Loan Companies Act
(Canada) or under comparable legislation in a jurisdiction of Canada or a foreign jurisdiction, acting on behalf of a fully managed account managed by the trust company or trust corporation, as the case may be,
|
☐
|
(l)
|
a person acting on behalf of a fully managed account managed by that person, if that person is registered or authorized to carry on business as an adviser or the equivalent under the securities legislation of a jurisdiction of Canada or a foreign jurisdiction,
|
☐
|
(m)
|
a registered charity under the
Income Tax Act
(Canada) that, in regard to the trade, has obtained advice from an eligibility adviser or an adviser registered under the securities legislation of the jurisdiction of the registered charity to give advice on the securities being traded,
|
☐
|
(n)
|
an entity organized in a foreign jurisdiction that is analogous to the entity referred to in paragraph (a) in form and function,
|
☐
|
(o)
|
a person in respect of which all of the owners of interests, direct, indirect or beneficial, except the voting securities required by law to be owned by directors, are persons that are accredited investors,
|
☐
|
(p)
|
an investment fund that is advised by a person registered as an adviser or a person that is exempt from registration as an adviser,
|
☐
|
(q)
|
a person that is recognized or designated by the securities regulatory authority or, except in Ontario and Québec, the regulator as an accredited investor, or
|
☐
|
(r)
|
a trust established by an accredited investor for the benefit of the accredited investor’s family members of which a majority of the trustees are accredited investors and all of the beneficiaries are the accredited investor’s spouse, a former spouse of the accredited investor or a parent, grandparent, brother, sister, child or grandchild of that accredited investor, of that accredited investor’s spouse or of that accredited investor’s former spouse.
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|
WARNING!
This investment is risky. Don’t invest unless you can afford to lose all the money you pay for this investment.
|
·
Either alone or with your spouse, you own more than $1 million in cash and securities, after subtracting any debt related to the cash and securities.
|
|||
·
Either alone or with your spouse, you have net assets worth more than $5 million. (Your net assets are your total assets (including real estate) minus your total debt.)
|
|||
4.
Your name and signature
|
|||
By signing this form, you confirm that you have read this form and you understand the risks of making this investment as identified in this form.
|
|||
First and last name (please print):
|
|||
Signature:
|
Date:
|
||
SECTION 5 TO BE COMPLETED BY THE SALESPERSON
|
|||
5. Salesperson information
|
|||
First and last name of salesperson (please print):
|
|||
Telephone:
|
Email:
|
||
Name of firm (if registered): not applicable
|
|||
SECTION 6 TO BE COMPLETED BY THE ISSUER OR SELLING SECURITY HOLDER
|
|||
6. For more information about this investment
|
|||
For investment in a non-investment fund
|
|||
AppCoin Innovations Inc.
|
|||
3250 Oakland Hills Court
Fairfield, CA 94534
USA
|
|||
James P. Geiskopf
|
|||
(707) 208-6368
|
|||
jgeiskopf@aol.com
|
|||
|
|||
For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at www.securities-administrators.ca.
|
1.
|
it is not resident in Canada;
|
2.
|
it has such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Note and it is able to bear the economic risk of loss of its entire investment;
|
3.
|
the Issuer has provided to it the opportunity to ask questions and receive answers concerning the terms and conditions of the Offering and it has had access to such information concerning the Issuer as it has considered necessary or appropriate in connection with its investment decision to acquire the Note;
|
4.
|
it is acquiring the Note for its own account, for investment purposes only and not with a view to any resale, distribution or other disposition of the Securities in violation of the United States securities laws;
|
5.
|
it (i) has adequate net worth and means of providing for its current financial needs and possible personal contingencies, (ii) has no need for liquidity in this investment, and (iii) is able to bear the economic risks of an investment in the Note for an indefinite period of time;
|
6.
|
if the Subscriber is an individual (that is, a natural person and not a corporation, partnership, trust or other entity), then it satisfies one or more of the categories indicated below (please place an “X” on the appropriate lines):
|
___________
|
a natural person whose individual net worth, or joint net worth with their spouse, 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,
|
___________
|
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 their 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, or
|
___________
|
a director or executive officer of the Issuer;
|
7.
|
if the Subscriber is a corporation, partnership, trust or other entity), then it satisfies one or more of the categories indicated below (please place an “X” on the appropriate lines):
|
___________
|
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 Note, with total assets in excess of US$5,000,000,
|
___________
|
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 US$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 US$5,000,000, or, if a self-directed plan, whose investment decisions are made solely by persons that are accredited investors,
|
___________
|
a private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940
(United States),
|
___________
|
a trust with total assets in excess of US$5,000,000, not formed for the specific purpose of acquiring the Note, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) under the 1933 Act, or
|
___________
|
an entity in which all of the equity owners satisfy the requirements of one or more of the categories set forth in Section 6 above.
|
8.
|
it has not purchased the Note 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, internet, television or other form of telecommunications, or any seminar or meeting whose attendees have been invited by general solicitation or general advertising;
|
9.
|
if the Subscriber decides to offer, sell or otherwise transfer any of the Securities, it will not offer, sell or otherwise transfer any of such Securities directly or indirectly, unless:
|
(a)
|
the sale is to the Issuer,
|
(b)
|
the sale is made outside the United States in a transaction meeting the requirements of Rule 904 of Regulation S under the 1933 Act and in compliance with applicable local laws and regulations in which such sale is made;
|
(c)
|
the sale is made pursuant to the exemption from the registration requirements under the 1933 Act provided by Rule 144 thereunder and in accordance with any applicable state securities or “blue sky” laws, or
|
(d)
|
the Securities are sold in a transaction that does not require registration under the 1933 Act or any applicable state laws and regulations governing the offer and sale of securities, and
|
(e)
|
it has prior to such sale pursuant to subsection (c) or (d) furnished to the Issuer an opinion of counsel of recognized standing reasonably satisfactory to the Issuer, to such effect;
|
10.
|
it understands and acknowledges that upon the issuance thereof, and until such time as the same is no longer required under the applicable requirements of the 1933 Act or applicable U.S. state laws and regulations, the certificates representing the Securities, and all securities issued in exchange therefor or in substitution thereof, will bear a legend in substantially the following form:
|
11.
|
it understands and agrees that there may be material tax consequences to the Subscriber of an acquisition or disposition of any of the Securities. The Issuer gives no opinion and makes no representation with respect to the tax consequences to the Subscriber under United States, state, local or foreign tax law of the Subscriber’s acquisition or disposition of the Securities;
|
12.
|
it consents to the Issuer making a notation on its records or giving instructions to any transfer agent of the Issuer in order to implement the restrictions on transfer set forth and described in this Questionnaire and the Agreement;
|
13.
|
it is resident in the United States of America, its territories and possessions or any state of the United States or the District of Columbia (collectively the “
United States
”), is a “U.S. Person” as such term is defined in Regulation S or was in the United States at the time the Note were offered or the Agreement was executed; and
|
14.
|
it understands that the Issuer has no obligation to register any of the Securities or to take action so as to permit sales pursuant to the 1933 Act (including Rule 144 thereunder).
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|
Issue Date: October 30, 2017
|
Principal Amount: $_____________
|
1.
|
General
|
2.
|
Definitions
|
(a)
|
“
Business Day
” means any day except Saturday, Sunday and any day which is a federal legal holiday in the United States or a day on which banking institutions in the State of California are authorized or required by law or other government action to close;
|
(b)
|
“
Conversion Date
” means the Business Day after the Holder provides the Conversion Notice to the Company for the conversion of any portion of the Principal Amount and accrued interest thereon into Conversion Shares pursuant to the terms of this Note;
|
(c)
|
“
Conversion Notice
” has the meaning set forth in Section 5.2;
|
(d)
|
“
Conversion Price
” means $0.10 per Conversion Share, subject to adjustment as provided in Section 5.7;
|
(e)
|
“
Conversion Share
” means a Share into which the Principal Amount, and accrued interest thereon, may be converted pursuant to the terms of this Note;
|
(f)
|
“
Issue Date
” has the meaning set forth on the first page of this Note;
|
(g)
|
“
Party
” means either the Company or the Holder, as applicable, and “
Parties
” means both of them;
|
(h)
|
“
Person
” means any individual, sole proprietorship, limited or unlimited liability corporation, partnership, unincorporated association, unincorporated syndicate, unincorporated organization, body corporate, joint venture, trust, pension fund, union, governmental authority, and a natural person including in such person’s capacity as trustee, heir, beneficiary, executor, administrator or other legal representative;
|
(i)
|
“
Share
” means a share of common stock in the capital of the Company; and
|
(j)
|
“
Subscription Agreement
” means the private placement subscription agreement between the Parties dated as of the Issue Date,
as amended, modified or supplemented from time to time in accordance with its terms.
|
3.
|
Subscription Agreement
|
4.
|
Interest
|
5.
|
Conversion
|
6.
|
Repayment
|
7.
|
Prepayment
|
8.
|
Event of Default
|
(a)
|
the Company defaults in the payment of any amounts owing under this Note when due and the Company fails to cure such default within ten (10) Business Days after written notice of default is sent by the Holder to the Company;
|
(b)
|
the Company fails to issue the Conversion Shares within ten (10) Business Days after a Conversion Notice is delivered to the Company;
|
(c)
|
the Company files a voluntary petition in bankruptcy or is adjudicated bankrupt or insolvent, or files any petition or answer seeking or acquiescing in any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief for itself under any present or future federal, state or other statute, law or regulation relating to bankruptcy, insolvency or other relief for debtors; or seeks, consents to, or acquiesces in, the appointment of any trustee, receiver or liquidator of the Company;
|
(d)
|
a court of competent jurisdiction enters an order, judgment or decree approving a petition filed against the Company seeking any reorganization, dissolution or similar relief under any present or future federal, state or other statute, law or regulation relating to bankruptcy, insolvency or other relief for debtors, and such order, judgment or decree remains unvacated and unstayed for an aggregate of 60 Business Days (whether or not consecutive) from the first date of entry thereof; or any trustee, receiver or liquidator of the Company is appointed without the consent or acquiescence of the Company and such appointment remains unvacated and unstayed for an aggregate of 60 Business Days (whether or not consecutive); or
|
(e)
|
the Company ceases or threatens to cease to carry on its business.
|
9.
|
Notices
|
10.
|
Replacement of Note if Lost or Destroyed
|
11.
|
Governing Law
|
12.
|
Waivers
|
13.
|
Usury
|
14.
|
Next Business Day
|
15.
|
Counterparts and Electronic Means
|
APPCOIN INNOVATIONS INC.
Per: ______________________________________________
Authorized Signatory
Name: ____________________________________________ |
___________________________
Per: ______________________________________________
Authorized Signatory
Name:_____________________________________________ |
1. |
You must complete all the information in the boxes on page 2 and sign where indicated with an “
X
”.
|
2. |
If you are resident in Canada, you must complete and sign Exhibit A “Canadian Investor Questionnaire” that starts on page 12. The purpose of this form is to determine whether you meet the standards for participation in a private placement under applicable Canadian securities laws. In order for the Issuer to satisfy its obligations under applicable Canadian securities laws, you may be required to provide additional evidence to verify the information you have provided in Exhibit A “Canadian Investor Questionnaire” that starts on page 12.
|
3. |
If you are a “U.S. Purchaser”, as defined in Exhibit B, you must complete and sign Exhibit B “United States Accredited Investor Questionnaire” that starts on page 21
.
|
Subscriber Information
____________________________________________________________________
|
Shares to be Purchased
Number of Shares: ________________________________
Total Subscription Price: $__________________________
(the “
Subscription Amount
”)
|
|
(Name of Subscriber)
|
||
Account Reference (if applicable): __________________________________________
|
||
X____________________________________________________________________
|
||
(Signature of Subscriber – if the Subscriber is an Individual)
|
||
X____________________________________________________________________
|
||
(Signature of Authorized Signatory – if the Subscriber is not an Individual)
____________________________________________________________________
(Name and Title of Authorized Signatory – if the Subscriber is not an Individual)
____________________________________________________________________
(SIN, SSN, or other Tax Identification Number of the Subscriber)
____________________________________________________________________
(Subscriber’s Address, including City and Postal Code)
____________________________________________________________________
____________________________________________________________________
(Telephone Number)_________________________________
(Email Address)__________________________
|
||
Register the Shares as set forth below
:
____________________________________________________________________
(Name to Appear on Share Certificate)
____________________________________________________________________
(Account Reference, if applicable)
____________________________________________________________________
(Address, including Postal Code)
|
Address: |
AppCoin Innovations Inc.
3250 Oakland Hills Court Fairfield, CA 94534 USA |
Email: |
jgeiskopf@aol.com
|
Attention: |
James P. Geiskopf
|
(a)
|
this Agreement;
|
(b)
|
if the Subscribers is a resident of Canada, the Canadian Investor Questionnaire (the “
Canadian Questionnaire
”) attached as Exhibit A that starts on page , along with any additional evidence that may be requested by the Issuer to verify the information provided in the Canadian Questionnaire;
|
(c)
|
if the Subscriber is a U.S. Purchaser (as defined in Exhibit B), the United States Accredited Investor Questionnaire (the “
U.S. Questionnaire
” and, together with the Canadian Questionnaire, the “
Questionnaires
”) attached as Exhibit B that starts on page ; and
|
(d)
|
such other supporting documentation that the Issuer or counsel of the Issuer (the “
Issuer’s Counsel
”) may request to establish the Subscriber’s qualification as a qualified investor,
|
(e)
|
and the Subscriber acknowledges and agrees that the Issuer will not consider the Subscription for acceptance unless the Subscriber has provided all of such documents to the Issuer.
|
(a)
|
the Issuer having obtained all necessary approvals and consents, including regulatory approvals for the Offering; and
|
(b)
|
the issue and sale of the Shares being exempt from the requirement to file a prospectus and the requirement to deliver an offering memorandum under applicable securities laws relating to the sale of the Shares, or the Issuer having received such orders, consents or approvals as may be required to permit such sale without the requirement to file a prospectus or deliver an offering memorandum.
|
(a)
|
none of the Shares have been or will be registered under the United States
Securities Act of 1933
, as amended, (the “
1933 Act
”), or under any 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 any U.S. Person (as defined in Section 6.2), except in accordance with the provisions of Regulation S under the 1933 Act (“
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, provincial and foreign securities laws;
|
(b)
|
the Issuer has not undertaken, and will have no obligation, to register any of the Shares under the 1933 Act or any other applicable securities laws;
|
(c)
|
the Issuer will refuse to register the transfer of any of the Shares to a U.S. Person not made pursuant to an effective registration statement under the 1933 Act or pursuant to an available exemption from the registration requirements of the 1933 Act and in each case in accordance with applicable laws;
|
(d)
|
the decision to execute this Agreement and to acquire the Shares has not been based upon any oral or written representation as to fact or 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 United State Securities and Exchange Commission (collectively, the “
Public Record
”);
|
(e)
|
the Issuer and others will rely upon the truth and accuracy of the acknowledgements, representations, warranties, covenants and agreements of the Subscriber contained in this Agreement and the Questionnaires, as applicable, and agrees that if any of such acknowledgements, representations and agreements are no longer accurate or have been breached, the Subscriber will promptly notify the Issuer;
|
(f)
|
there are risks associated with the purchase of the Shares, as more fully described in the Issuer’s periodic disclosure forming part of the Public Record;
|
(g)
|
the Subscriber and the Subscriber’s advisor(s) have had a reasonable opportunity to ask questions of and receive answers from the Issuer in connection with the distribution of the Shares hereunder, and to obtain additional information, to the extent possessed or obtainable without unreasonable effort or expense, necessary to verify the accuracy of the information about the Issuer;
|
(h)
|
a portion of this Offering may be sold pursuant to an agreement between the Issuer and one or more agents registered in accordance with applicable securities laws, in which case the Issuer will pay a fee and/or compensation securities on terms as set out in such agency agreement;
|
(i)
|
finder’s fees or broker’s commissions may be payable by the Issuer to finders who introduce subscribers to the Issuer;
|
(j)
|
the books and records of the Issuer were 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 all documents, records and books in connection with the distribution of the Shares hereunder have been made available for inspection by the Subscriber, the Subscriber’s legal counsel and/or its advisor(s);
|
(k)
|
all of the information which the Subscriber has provided to the Issuer is correct and complete and if there should be any change in such information prior to the Closing, the Subscriber will immediately notify the Issuer, in writing, with the details of any such change;
|
(l)
|
the Issuer is entitled to rely on the representations and warranties of the Subscriber contained in this Agreement and the Questionnaires, as applicable, and the Subscriber will hold harmless the Issuer from any loss or damage it or they may suffer as a result of the Subscriber’s failure to correctly complete this Agreement or the Questionnaires, as applicable;
|
(m)
|
any resale of the Shares by the Subscriber will be subject to resale restrictions contained in the securities laws applicable to the Issuer, the Subscriber and any proposed transferee and it is the responsibility of the Subscriber to find out what those restrictions are and to comply with such restrictions before selling any of the Shares;
|
(n)
|
the Subscriber has been advised to consult the Subscriber’s own legal, tax and other advisors with respect to the merits and risks of an investment in the Shares and with respect to applicable resale restrictions, and it is solely responsible (and the Issuer is not in any way responsible) for compliance with:
|
(i)
|
any applicable laws of the jurisdiction in which the Subscriber is resident in connection with the distribution of the Shares hereunder, and
|
(ii)
|
applicable resale restrictions;
|
(o)
|
there may be material tax consequences to the Subscriber of an acquisition or disposition of the Shares and the Issuer gives no opinion and makes no representation to the Subscriber with respect to the tax consequences to the Subscriber under federal, state, provincial, local or foreign tax laws that may apply to the Subscriber’s acquisition or disposition of the Shares;
|
(p)
|
the Subscriber consents to the placement of a legend or legends on any certificate or other document evidencing any of the Shares setting forth or referring to the restrictions on transferability and sale thereof contained in this Agreement;
|
(q)
|
the Issuer has advised the Subscriber that the Issuer is relying on an exemption from the requirements to provide the Subscriber with a prospectus and to sell the Shares through a person registered to sell securities under provincial securities laws and other applicable securities laws, and, as a consequence of acquiring the Shares pursuant to such exemption, certain protections, rights and remedies provided by applicable securities laws (including the various provincial securities acts), including statutory rights of rescission or damages, will not be available to the Subscriber;
|
(r)
|
no securities commission or similar regulatory authority has reviewed or passed on the merits of any of the Shares;
|
(s)
|
there is no government or other insurance covering any of the Shares; and
|
(t)
|
this Agreement is not enforceable by the Subscriber unless it has been accepted by the Issuer, and the Issuer reserves the right to reject this Subscription for any reason.
|
(a)
|
unless the Subscriber has completed Exhibit B, the Subscriber is not a U.S. Person;
|
(b)
|
the Subscriber is resident in the jurisdiction set out on page 2 of this Agreement;
|
(c)
|
if the Subscriber is resident outside of Canada:
|
(i)
|
the Subscriber is knowledgeable of, or has been independently advised as to, the applicable securities laws having application in the jurisdiction in which the Subscriber is resident (the “
International Jurisdiction
”) which would apply to the offer and sale of the Shares,
|
(ii)
|
the Subscriber is purchasing the Shares pursuant to exemptions from prospectus or equivalent requirements under applicable securities laws or, if such is not applicable, the Subscriber is permitted to purchase the Shares under the applicable laws of the International Jurisdiction without the need to rely on any exemptions,
|
(iii)
|
the applicable laws of the authorities in the International Jurisdiction do not require the Issuer to make any filings or seek any approvals of any kind whatsoever from any securities regulator of any kind whatsoever in the International Jurisdiction in connection with the offer, issue, sale or resale of any of the Shares,
|
(iv)
|
the purchase of the Shares by the Subscriber does not trigger:
|
A.
|
any obligation to prepare and file a prospectus or similar document, or any other report with respect to such purchase in the International Jurisdiction, or
|
B.
|
any continuous disclosure reporting obligation of the Issuer in the International Jurisdiction, and
|
(v)
|
the Subscriber will, if requested by the Issuer, deliver to the Issuer a certificate or opinion of local counsel from the International Jurisdiction which will confirm the matters referred to in subparagraphs (ii), (iii) and (iv) above to the satisfaction of the Issuer, acting reasonably;
|
(d)
|
the Subscriber has the legal capacity and competence to enter into and execute this Agreement and to take all actions required pursuant hereto and, if the Subscriber is a corporate entity, it is duly incorporated and validly subsisting under the laws of its jurisdiction of incorporation and all necessary approvals by its directors, shareholders and others have been obtained to authorize execution and performance of this Agreement on behalf of the Subscriber;
|
(e)
|
the entering into of this 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;
|
(f)
|
the Subscriber has duly executed and delivered this Agreement and it constitutes a valid and binding agreement of the Subscriber enforceable against the Subscriber;
|
(g)
|
the Subscriber has received and carefully read this Agreement;
|
(h)
|
the Subscriber is aware that an investment in the Issuer is speculative and involves certain risks (including those risks disclosed in the Public Record), including the possible loss of the entire investment;
|
(i)
|
the Subscriber has made an independent examination and investigation of an investment in the Shares and the Issuer and agrees that the Issuer will not be responsible in any way for the Subscriber’s decision to invest in the Shares and the Issuer;
|
(j)
|
the Subscriber is not an underwriter of, or dealer in, any of the Shares, nor is the Subscriber participating, pursuant to a contractual agreement or otherwise, in the distribution of the Shares;
|
(k)
|
the Subscriber is not aware of any advertisement of any of the Shares and is not acquiring the Shares 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
|
(l)
|
no person has made to the Subscriber any written or oral representations:
|
(i)
|
that any person will resell or repurchase any of the Shares,
|
(ii)
|
that any person will refund the purchase price of any of the Shares, or
|
(iii)
|
as to the future price or value of any of the Shares.
|
(a)
|
the Issuer may deliver to any securities commission having jurisdiction over the Issuer, the Subscriber or this Subscription, including any Canadian provincial securities commissions, the United States Securities and Exchange Commission and/or any state securities commissions (collectively, the “
Commissions
”), certain personal information pertaining to the Subscriber, including the Subscriber’s full name, residential address and telephone number, the number of securities of the Issuer owned by the Subscriber, the number of Shares purchased by the Subscriber, the total Subscription Amount paid, the prospectus exemption relied on by the Issuer and the date of distribution of the Shares;
|
(b)
|
such information is being collected indirectly by the Commissions under the authority granted to them in applicable securities laws;
|
(c)
|
such information is being collected for the purposes of the administration and enforcement of applicable securities laws; and
|
(d)
|
the Subscriber may contact the following public official in Ontario with respect to questions about the Ontario Securities Commission’s indirect collection of such information at the following address and telephone number:
|
(e)
|
Administrative Assistant to the Director of Corporate Finance
Ontario Securities Commission Suite 1903, Box 55 20 Queen Street West Toronto, ON M5H 3S8 Telephone: (416) 593-8086 |
(i) |
is purchasing the Shares as principal (or deemed principal under the terms of National Instrument 45-106 -
Prospectus Exemptions
adopted by the Canadian Securities Administrators (“
NI 45-106
”));
|
(ii) | (A) | is resident in or is subject to the laws of one of the following (check one): |
(B) |
☐
is resident in a country other than Canada or the United States; and
|
(iii) |
has not been provided with any offering memorandum in connection with the purchase of the Shares.
|
I.
SUBSCRIBERS PURCHASING UNDER THE “ACCREDITED INVESTOR” EXEMPTION
|
|
(a)
|
the Subscriber is not a trust company or trust company registered under the laws of Prince Edward Island that is not registered or authorized under the
Trust and Loan Companies Act
(Canada) or under comparable legislation in another jurisdiction of Canada;
|
(b)
|
the Subscriber is an “accredited investor” within the meaning of NI 45-106, by virtue of satisfying the indicated criterion as set out in Appendix “A” to this certificate
(YOU MUST ALSO INITIAL OR PLACE A CHECK-MARK ON THE APPROPRIATE LINE IN APPENDIX “A” ATTACHED TO THIS CERTIFICATE)
|
(c)
|
If the Subscriber is an “accredited investor” within the meaning of NI 45-106 by virtue of satisfying the indicated criterion as set out in paragraphs (d), (f) or (g) of Appendix “A” to this certificate, the Subscriber has provided the Issuer with the signed risk acknowledgement form set out in Appendix “B” to this certificate;
|
II.
MINIMUM AMOUNT INVESTMENT
|
|
(a)
|
the Subscriber is not an individual as that term is defined in applicable Canadian securities laws.
|
(b)
|
the Subscriber is purchasing the Shares as principal for its own account and not for the benefit of any other person;
|
(c)
|
the Shares have an acquisition cost to the Subscriber of not less than $150,000, payable in cash at the Closing; and
|
(d)
|
the Subscriber was not created and is not being used solely to purchase or hold securities in reliance on the prospectus exemption provided under Section 2.10 of NI 45-106, it pre-existed the Offering and has a bona fide purpose other than investment in the Shares.
|
(i) |
one of them is the subsidiary of the other, or
|
(ii) |
each of them is controlled by the same person;
|
(i) |
a person who holds a sufficient number of the voting rights attached to all outstanding voting securities of an issuer to affect materially the control of the issuer, or
|
(ii) |
each person in a combination of persons, acting in concert by virtue of an agreement, arrangement, commitment or understanding, which holds in total a sufficient number of the voting rights attached to all outstanding voting securities of an issuer to affect materially the control of the issuer,
|
(i) |
a member of the board of directors of a company or an individual who performs similar functions for a company, and
|
(ii) |
with respect to a person that is not a company, an individual who performs functions similar to those of a director of a company;
|
(i) |
a person that is registered as an investment dealer and authorized to give advice with respect to the type of security being distributed; and
|
(ii) |
in Saskatchewan or Manitoba, also means a lawyer who is a practicing member in good standing with a law society of a jurisdiction of Canada or a public accountant who is a member in good standing of an institute or association of chartered accountants, certified general accountants or certified management accountants in a jurisdiction of Canada provided that the lawyer or public accountant must not:
|
(A) |
have a professional, business or personal relationship with the issuer, or any of its directors, executive officers, founders or control persons, and
|
(B) |
have acted for or been retained personally or otherwise as an employee, executive officer, director, associate or partner of a person that has acted for or been retained by the issuer or any of its directors, executive officers, founders or control persons within the previous 12 months;
|
(i) |
a chair, vice-chair or president,
|
(ii) |
a vice-president in charge of a principal business unit, division or function including sales, finance or production, or
|
(iii) |
performing a policy-making function in respect of the issuer;
|
(i) |
cash,
|
(ii) |
securities, or
|
(iii) |
a contract of insurance, a deposit or an evidence of a deposit that is not a security for the purposes of securities legislation;
|
(g) |
“
foreign jurisdiction
” means a country other than Canada or a political subdivision of a country other than Canada;
|
(i) |
acting alone, in conjunction, or in concert with one or more persons, directly or indirectly, takes the initiative in founding, organizing or substantially reorganizing the business of the issuer, and
|
(ii) |
at the time of the distribution or trade is actively involved in the business of the issuer;
|
(i) |
“
fully managed account
” means an account of a client for which a person makes the investment decisions if that person has full discretion to trade in securities for the account without requiring the client’s express consent to a transaction;
|
(j) |
“
individual
” means a natural person, but does not include
|
(i) |
a partnership, unincorporated association, unincorporated syndicate, unincorporated organization or trust, or
|
(ii) |
a natural person in the person's capacity as a trustee, executor, administrator or personal or other legal representative;
|
(k) |
“
investment fund
” means a mutual fund or a non-redeemable investment fund, and, for great certainty in British Columbia, includes an employee venture capital corporation and a venture capital corporation as such terms are defined in National Instrument 81-106
Investment Fund Continuous Disclosure
;
|
(l) |
“
jurisdiction
” or “jurisdiction of Canada” means a province or territory of Canada except when used in the term foreign jurisdiction;
|
(m) |
“
non-redeemable investment fund
” means an issuer:
|
(A) |
for the purpose of exercising or seeking to exercise control of an issuer, other than an issuer that is a mutual fund or a non-redeemable investment fund, or
|
(B) |
for the purpose of being actively involved in the management of any issuer in which it invests, other than an issuer that is a mutual fund or a non-redeemable investment fund, and
|
(i) |
an individual;
|
(ii) |
a corporation;
|
(iii) |
a partnership, trust, fund and an association, syndicate, organization or other organized group of persons, whether incorporated or not; and
|
(iv) |
an individual or other person in that person’s capacity as a trustee, executor, administrator or personal or other legal representative;
|
(i) |
liabilities incurred or assumed for the purpose of financing the acquisition or ownership of financial assets, or
|
(ii) |
liabilities that are secured by financial assets; and
|
(i) |
is married to another individual and is not living separate and apart within the meaning of the
Divorce Act
(Canada), from the other individual,
|
(ii) |
is living with another individual in a marriage-like relationship, including a marriage-like relationship between individuals of the same gender, or
|
(iii) |
in Alberta, is an individual referred to in paragraph (i) or (ii), or is an adult interdependent partner within the meaning of the
Adult Interdependent Relationships Act
(Alberta).
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|
☐
|
(a)
|
except in Ontario, a person registered under the securities legislation of a jurisdiction of Canada as an adviser or dealer,
|
☐
|
(b)
|
an individual registered under the securities legislation of a jurisdiction of Canada as a representative of a person referred to in paragraph (a),
|
☐
|
(c)
|
an individual formerly registered under the securities legislation of a jurisdiction of Canada, other than an individual formerly registered solely as a representative of a limited market dealer under one or both of the
Securities Act
(Ontario) or the
Securities Act
(Newfoundland and Labrador),
|
☐
|
(d)
|
an individual who, either alone or with a spouse, beneficially owns financial assets having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $1,000,000
(YOU MUST INDICATE YOUR FINANCIAL ASSETS HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(e)
|
an individual who beneficially owns financial assets having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $5,000,000,
|
☐
|
(f)
|
an individual whose net income before taxes exceeded $200,000 in each of the 2 most recent calendar years or whose net income before taxes combined with that of a spouse exceeded $300,000 in each of the 2 most recent calendar years and who, in either case, reasonably expects to exceed that net income level in the current calendar year
(YOU MUST INDICATE YOUR NET INCOME HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(g)
|
an individual who, either alone or with a spouse, has net assets of at least $5,000,000
(YOU MUST INDICATE YOUR NET ASSETS HERE: $
__________________________
☐
WITH SPOUSE /
☐
WITHOUT SPOUSE AND
ALSO COMPLETE THE RISK ACKNOWLEDGEMENT FORM IN APPENDIX “B” ATTACHED TO THIS CERTIFICATE)
,
|
☐
|
(h)
|
a person, other than an individual or investment fund, that has net assets of at least $5,000,000 as shown on its most recently prepared financial statements
and that has not been created or used solely to purchase or hold securities as an accredited investor as defined in this paragraph (h),
|
☐
|
(i)
|
an investment fund that distributes or has distributed its securities only to
(i)
a person that is or was an accredited investor at the time of the distribution,
(ii)
a person that acquires or acquired securities in the circumstances referred to in sections 2.10 [Minimum amount investment] of NI 45-106, or 2.19 [Additional investment in investment funds] of NI 45-106, or
(iii)
a person described in paragraph (i) or (ii) that acquires or acquired securities under section 2.18 [Investment fund reinvestment] of NI 45-106,
|
☐
|
(j)
|
an investment fund that distributes or has distributed securities under a prospectus in a jurisdiction of Canada for which the regulator or, in Québec, the securities regulatory authority, has issued a receipt,
|
☐
|
(k)
|
a trust company or trust corporation registered or authorized to carry on business under the
Trust and Loan Companies Act
(Canada) or under comparable legislation in a jurisdiction of Canada or a foreign jurisdiction, acting on behalf of a fully managed account managed by the trust company or trust corporation, as the case may be,
|
☐
|
(l)
|
a person acting on behalf of a fully managed account managed by that person, if that person is registered or authorized to carry on business as an adviser or the equivalent under the securities legislation of a jurisdiction of Canada or a foreign jurisdiction,
|
☐
|
(m)
|
a registered charity under the
Income Tax Act
(Canada) that, in regard to the trade, has obtained advice from an eligibility adviser or an adviser registered under the securities legislation of the jurisdiction of the registered charity to give advice on the securities being traded,
|
☐
|
(n)
|
an entity organized in a foreign jurisdiction that is analogous to the entity referred to in paragraph (a) in form and function,
|
☐
|
(o)
|
a person in respect of which all of the owners of interests, direct, indirect or beneficial, except the voting securities required by law to be owned by directors, are persons that are accredited investors,
|
☐
|
(p)
|
an investment fund that is advised by a person registered as an adviser or a person that is exempt from registration as an adviser,
|
☐
|
(q)
|
a person that is recognized or designated by the securities regulatory authority or, except in Ontario and Québec, the regulator as an accredited investor, or
|
☐
|
(r)
|
a trust established by an accredited investor for the benefit of the accredited investor’s family members of which a majority of the trustees are accredited investors and all of the beneficiaries are the accredited investor’s spouse, a former spouse of the accredited investor or a parent, grandparent, brother, sister, child or grandchild of that accredited investor, of that accredited investor’s spouse or of that accredited investor’s former spouse.
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|
WARNING!
This investment is risky. Don’t invest unless you can afford to lose all the money you pay for this investment.
|
SECTION 1 TO BE COMPLETED BY THE ISSUER OR SELLING SECURITY HOLDER
|
|
1.
About your investment
|
|
Type of securities: Shares of Common Stock
|
Issuer: AppCoin Innovations Inc.
|
Purchased from: Issuer
|
|
SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
|
|
2. Risk acknowledgement
|
|
This investment is risky. Initial that you understand that:
|
Your
initials |
Risk of loss
– You could lose your entire investment of $__________.
[Instruction: Insert the total dollar amount of the investment.]
|
|
Liquidity risk
– You may not be able to sell your investment quickly – or at all.
|
|
Lack of information
– You may receive little or no information about your investment.
|
|
Lack of advice
– You will not receive advice from the salesperson about whether this investment is suitable for you unless the salesperson is registered. The salesperson is the person who meets with, or provides information to, you about making this investment. To check whether the salesperson is registered, go to www.aretheyregistered.ca.
|
|
3. Accredited investor status
|
|
You must meet at least one of the following criteria to be able to make this investment. Initial the statement that applies to you. (You may initial more than one statement.) The person identified in section 6 is responsible for ensuring that you meet the definition of accredited investor. That person, or the salesperson identified in section 5, can help you if you have questions about whether you meet these criteria.
|
Your
initials |
·
Your net income before taxes was more than $200,000 in each of the 2 most recent calendar years, and you expect it to be more than $200,000 in the current calendar year. (You can find your net income before taxes on your personal income tax return.)
|
|
·
Your net income before taxes combined with your spouse’s was more than $300,000 in each of the 2 most recent calendar years, and you expect your combined net income before taxes to be more than $300,000 in the current calendar year.
|
·
Either alone or with your spouse, you own more than $1 million in cash and securities, after subtracting any debt related to the cash and securities.
|
|
·
Either alone or with your spouse, you have net assets worth more than $5 million. (Your net assets are your total assets (including real estate) minus your total debt.)
|
|
4.
Your name and signature
|
|
By signing this form, you confirm that you have read this form and you understand the risks of making this investment as identified in this form.
|
|
First and last name (please print):
|
|
Signature:
|
Date:
|
SECTION 5 TO BE COMPLETED BY THE SALESPERSON
|
|
5. Salesperson information
|
|
First and last name of salesperson (please print):
|
|
Telephone:
|
Email:
|
Name of firm (if registered): not applicable
|
|
SECTION 6 TO BE COMPLETED BY THE ISSUER OR SELLING SECURITY HOLDER
|
|
6. For more information about this investment
|
|
For investment in a non-investment fund
|
|
AppCoin Innovations Inc.
|
|
3250 Oakland Hills Court
Fairfield, CA 94534
USA
|
|
James P. Geiskopf
|
|
(707) 208-6368
|
|
jgeiskopf@aol.com
|
|
For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at www.securities-administrators.ca.
|
1.
|
it is not resident in Canada;
|
2.
|
it has such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Shares and it is able to bear the economic risk of loss of its entire investment;
|
3.
|
the Issuer has provided to it the opportunity to ask questions and receive answers concerning the terms and conditions of the Offering and it has had access to such information concerning the Issuer as it has considered necessary or appropriate in connection with its investment decision to acquire the Shares;
|
4.
|
it is acquiring the Shares for its own account, for investment purposes only and not with a view to any resale, distribution or other disposition of the Shares in violation of the United States securities laws;
|
5.
|
it (i) has adequate net worth and means of providing for its current financial needs and possible personal contingencies, (ii) has no need for liquidity in this investment, and (iii) is able to bear the economic risks of an investment in the Shares for an indefinite period of time;
|
6.
|
if the Subscriber is an individual (that is, a natural person and not a corporation, partnership, trust or other entity), then it satisfies one or more of the categories indicated below (please place an “X” on the appropriate lines):
|
___________
|
a natural person whose individual net worth, or joint net worth with their spouse, 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,
|
___________
|
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 their 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, or
|
___________
|
a director or executive officer of the Issuer;
|
7.
|
if the Subscriber is a corporation, partnership, trust or other entity), then it satisfies one or more of the categories indicated below (please place an “X” on the appropriate lines):
|
___________
|
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 Shares, with total assets in excess of US$5,000,000,
|
___________
|
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 US$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 US$5,000,000, or, if a self-directed plan, whose investment decisions are made solely by persons that are accredited investors,
|
___________
|
a private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940
(United States),
|
___________
|
a trust with total assets in excess of US$5,000,000, not formed for the specific purpose of acquiring the Shares, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii) under the 1933 Act, or
|
___________
|
an entity in which all of the equity owners satisfy the requirements of one or more of the categories set forth in Section 6 above.
|
8.
|
it has not purchased the Shares 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, internet, television or other form of telecommunications, or any seminar or meeting whose attendees have been invited by general solicitation or general advertising;
|
9.
|
if the Subscriber decides to offer, sell or otherwise transfer any of the Shares, it will not offer, sell or otherwise transfer any of such Shares directly or indirectly, unless:
|
(a)
|
the sale is to the Issuer,
|
(b)
|
the sale is made outside the United States in a transaction meeting the requirements of Rule 904 of Regulation S under the 1933 Act and in compliance with applicable local laws and regulations in which such sale is made;
|
(c)
|
the sale is made pursuant to the exemption from the registration requirements under the 1933 Act provided by Rule 144 thereunder and in accordance with any applicable state securities or “blue sky” laws, or
|
(d)
|
the Shares are sold in a transaction that does not require registration under the 1933 Act or any applicable state laws and regulations governing the offer and sale of securities, and
|
(e)
|
it has prior to such sale pursuant to subsection (c) or (d) furnished to the Issuer an opinion of counsel of recognized standing reasonably satisfactory to the Issuer, to such effect;
|
10.
|
it understands and acknowledges that upon the issuance thereof, and until such time as the same is no longer required under the applicable requirements of the 1933 Act or applicable U.S. state laws and regulations, the certificates representing the Shares, and all securities issued in exchange therefor or in substitution thereof, will bear a legend in substantially the following form:
|
11.
|
it understands and agrees that there may be material tax consequences to the Subscriber of an acquisition or disposition of any of the Shares. The Issuer gives no opinion and makes no representation with respect to the tax consequences to the Subscriber under United States, state, local or foreign tax law of the Subscriber’s acquisition or disposition of the Shares;
|
12.
|
it consents to the Issuer making a notation on its records or giving instructions to any transfer agent of the Issuer in order to implement the restrictions on transfer set forth and described in this Questionnaire and the Agreement;
|
13.
|
it is resident in the United States of America, its territories and possessions or any state of the United States or the District of Columbia (collectively the “
United States
”), is a “U.S. Person” as such term is defined in Regulation S or was in the United States at the time the Shares were offered or the Agreement was executed; and
|
14.
|
it understands that the Issuer has no obligation to register any of the Shares or to take action so as to permit sales pursuant to the 1933 Act (including Rule 144 thereunder).
|
X
|
||
Signature of individual (if Subscriber is an individual)
|
||
X
|
||
Authorized signatory (if Subscriber is not an individual)
|
||
Name of Subscriber (please print)
|
||
Name of authorized signatory (please print)
|