Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 2 contracts
Sources: Subscription Agreement (KeyOn Communications Holdings Inc.), Subscription Agreement (KeyOn Communications Holdings Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: President and Chief Executive Officer o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 2 contracts
Sources: Subscription Agreement (American Energy Fields, Inc.), Subscription Agreement (Yesdtc Holdings, Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092014, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092014, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)or preferred stock, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Securities is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Securities and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsSecurities. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Securities and whose subscription for and purchase of the Units Securities is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsSecurities, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsSecurities. ___________________________________ Name of Purchaser [please print] ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Signature of Co-Purchaser ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) THIS ESCROW AGREEMENT (this “Agreement”) is made as of August ___________________________________ Name , 2014, by and among DRONE AVIATION HOLDING CORP., a Nevada corporation (the “Company”), Sichenzia ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP, with an address at ▇▇ ▇▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇ (the “Escrow Agent”) and the Subscribers. Capitalized terms used but not defined herein shall have the meanings set forth in that certain form of CoSubscription Agreement, annexed hereto as Schedule I, as amended or supplemented from time-Purchaser [please print] ___________________________________ Signature of Coto-Purchaser I state that I am familiar with time, including all attachments, schedules and exhibits thereto (the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:“Subscription Agreement”).
Appears in 1 contract
Sources: Subscription Agreement (Drone Aviation Holding Corp.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Instructions: Check all boxes below which correctly describe you. o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. Check all boxes below which correctly describe you. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No Your initials (purchaser and co-purchaser, if applicable) are required for each item below: ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (KeyOn Communications Holdings Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092015, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092015 , on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)or preferred stock, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Units is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Securities is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Securities and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsSecurities. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Securities and whose subscription for and purchase of the Units Securities is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsSecurities, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsSecurities. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state I, ▇▇▇▇▇ ▇▇▇▇▇▇, hereby certify that I am familiar with the financial affairs Chief Executive Officer of Majesco Entertainment Company (the “Company”), a corporation organized and investment objectives existing under the Delaware General Corporation Law (the “DGCL”), and further do hereby certify: That pursuant to the authority expressly conferred upon the Board of Directors of the investor named above and reasonably believe that Company (the “Board”) by the Company’s Certificate of Incorporation, as amended (the “Certificate of Incorporation”), the Board on April 23, 2015, adopted the following resolutions creating a purchase series of the securities is a suitable investment for this investor and shares of Preferred Stock designated as 0% Series C Convertible Preferred Stock, none of which shares have been issued: RESOLVED, that the investorBoard designates the 0% Series C Convertible Preferred Stock and the number of shares constituting such series, either individually or together with his or her purchaser representativeand fixes the rights, understands powers, preferences, privileges and restrictions relating to such series in addition to any set forth in the terms Certificate of and is able to evaluate the merits of this offering. I acknowledgeIncorporation as follows:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092011, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092011, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residences) at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment o You are a non-U.S. Person (a “Reg S Person”), and as such Reg S Person, you hereby represent that the representations contained in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” paragraphs (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.1) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire through (7) below are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledgecorrect:
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Sources: Subscription Agreement (American Energy Fields, Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092011, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092011, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state 6▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇ A/C of Sichenzia R▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP A/C#: 92883436 ABA#: 0▇▇▇▇▇▇▇▇ SWIFT Code: C▇▇▇▇▇▇▇ Ref: B▇▇▇▇▇▇▇ GOLD CORP. THIS ESCROW AGREEMENT (this “Agreement”) is made as of ___ __, 2011, by and among BULLFROG GOLD CORP., a Nevada corporation, with an address at _______ (“Bullfrog”), and Sichenzia R▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP, with an address at 6▇ ▇▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇ (the “Escrow Agent”). Capitalized terms used but not defined herein shall have the meanings set forth in that I am familiar with certain form of Subscription Agreement, annexed hereto as Schedule I, as amended or supplemented from time-to-time, including all attachments, schedules and exhibits thereto (the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:“Subscription Agreement”).
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Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092010, on behalf of the Company. By: :_________________________________ Name: ▇▇▇▇▇▇ ▇. ▇▇▇▇ Title: Chief Executive Officer Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092010, on behalf of the Company. By: _________________________________ Name: ▇▇▇▇▇▇ ▇. ▇▇▇▇ Title: Chief Executive Officer o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities Shares in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (not including the value of your primary residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092014, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092014, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)or preferred stock, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Units is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Securities is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Securities and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsSecurities. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Securities and whose subscription for and purchase of the Units Securities is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsSecurities, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsSecurities. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state I, ▇▇▇▇▇ ▇▇▇▇▇▇, hereby certify that I am familiar with the financial affairs Chief Executive Officer of Majesco Entertainment Company (the “Company”), a corporation organized and investment objectives existing under the Delaware General Corporation Law (the “DGCL”), and further do hereby certify: That pursuant to the authority expressly conferred upon the Board of Directors of the investor named above and reasonably believe that Company (the “Board”) by the Company’s Certificate of Incorporation, as amended (the “Certificate of Incorporation”), the Board on December 10, 2014 adopted the following resolutions creating a purchase series of the securities is a suitable investment for this investor and shares of Preferred Stock designated as 0% Series A Convertible Preferred Stock, none of which shares have been issued: RESOLVED, that the investorBoard designates the 0% Series A Convertible Preferred Stock and the number of shares constituting such series, either individually or together with his or her purchaser representativeand fixes the rights, understands powers, preferences, privileges and restrictions relating to such series in addition to any set forth in the terms Certificate of and is able to evaluate the merits of this offering. I acknowledgeIncorporation as follows:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092011, on behalf of the Company. By: :_________________________________ Name: A▇▇▇▇▇ ▇▇▇▇▇▇ Title: President and Chief Executive Officer Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092011, on behalf of the Company. By: _________________________________ Name: A▇▇▇▇▇ ▇▇▇▇▇▇ Title: President and Chief Executive Officer o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092010, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092010, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units theUnits is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residences) at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment o You are a non-U.S. Person(a “Reg S Person”), and as such Reg S Person, you hereby represent that the representations contained in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” paragraphs (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.1) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire through (7) below are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledgecorrect:
Appears in 1 contract
Sources: Subscription Agreement (American Energy Fields, Inc.)
Telephone Number Telephone Number. Fax Number (if available) _________________________________ Fax Number (if available) _________________________________ E-Mail (if available) _________________________________ E-Mail (if available) __________________________________ (Signature) _________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (KeyOn Communications Holdings Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Instructions: Check all boxes below which correctly describe you. o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock of the Company (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn CommunicationsCustomer Acquisition Network, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. Check all boxes below which correctly describe you. With respect to this investment in the UnitsShares, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No Your initials (purchaser and co-purchaser, if applicable) are required for each item below: ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (Customer Acquisition Network Holdings, Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) E-Mail (if available) E-Mail (if available) (Signature) (Signature of Additional Subscriber) ACCEPTED this day of 201___, on behalf of the Company. By: Name: ▇▇▇▇▇▇ ▇▇▇▇▇▇ Title: President {JK00876051.1 }12 _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ Name of Entity (SignaturePlease Print) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009201___, on behalf of the Company. By: _________________________________ Name: :▇▇▇▇▇▇ ▇▇▇▇▇▇ Title: o President {JK00876051.1 }13 [] You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o [] You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o [] You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o [] You are a director or executive officer of KeyOn Communications, Inc. o the Company. [] You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding your principal residence) at the time of your subscription for and purchase of the UnitsShares. o [] You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o [] You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o [] You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Common Stock Subscription Agreement (Feel the World, Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ /s/ S▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ 16 day of _________ 2009June 2008, on behalf of the Company. By: _________________________________ /s/ M▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ Name: M▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ Title: Chief Executive Officer Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092008, on behalf of the Company. By: _________________________________ Name: Title: Instructions: Check all boxes below which correctly describe you. o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Units is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities and with total assets in excess of $5,000,000. o You are a director or executive officer of KeyOn CommunicationsCustomer Acquisition Network Holdings, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and its underlying securities, whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. Check all boxes below which correctly describe you. With respect to this investment in the UnitsUnits and its underlying securities, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No Your initials (purchaser and co-purchaser, if applicable) are required for each item below: ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (Customer Acquisition Network Holdings, Inc.)
Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available) ______________________________________ Fax Number (if available) _____________________________________ E-Mail (if available) E-Mail (if available) -------------------------------------- ------------------------------------- (Signature) (Signature of Additional Subscriber) ACCEPTED this ________________________ day of _________ E-Mail 2006, on behalf of Akeena Solar, Inc. By: ------------------------------------ Name: Title: EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY (if availableCorporation, Partnership, Trust, Etc.) __________________________________ (Signature) _______________________________________________ Name of Entity (Signature Please Print) Date of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. ByIncorporation or Organization: _________________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: _____________________________________________________ Federal Taxpayer Identification Number: ________________________________________ ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] By: ------------------------------------ Name: Attest: _________________________________ Title: (If Entity is a Corporation) *IF SUBSCRIBER IS A REGISTERED REPRESENTATIVE WITH AN NASD MEMBER FIRM, HAVE THE FOLLOWING ACKNOWLEDGEMENT SIGNED BY THE APPROPRIATE PARTY: The undersigned NASD member firm acknowledges receipt of the notice required by Rule 3050 of the NASD Conduct Rules ACCEPTED this ________________________ day of __________ _________________________________ Address ACCEPTED this ____ day of __________ 20092006, on behalf of the Company. Akeena Solar, Inc. Name of NASD Firm By: _________________________________ By: --------------------------------- ------------------------------------ Name: Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) Title: Table of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:Contents
Appears in 1 contract
Sources: Subscription Agreement (Fairview Energy Corporation, Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092008, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092008, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn CommunicationsOptions Acquisition Sub, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available) E-Mail E-Mail (if available) (Signature) (Signature of Additional Purchaser) ACCEPTED this __________________ day of _______________ Fax Number 2017, on behalf of the Company. By: Chief Executive Officer EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if availablee.g., corporation, partnership, LLC, trust, etc.) __________________________________ (Signature) ____________________________________________ Name of Entity (Signature Please Print) Date of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. ByIncorporation or Organization: _____________________________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: ________________________________________________________________ Federal Taxpayer Identification Number: ____________________________________________________ ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: Name: Title: Address ACCEPTED this ___________________ day of _______________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092017, on behalf of the Company. By: _________________________________ NameChief Executive Officer Appendix A INVESTOR QUESTIONNAIRE Instructions: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, Check all boxes below which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high riskcorrectly describe you.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: KeyOn Subscription Agreement 0909 - 8 - Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: KeyOn Subscription Agreement 0909 - 9 - o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. KeyOn Subscription Agreement 0909 - 10 - With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser KeyOn Subscription Agreement 0909 - 11 - I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (KeyOn Communications Holdings Inc.)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) (Signature) (Signature of Additional Subscriber) ACCEPTED this day of 201___, on behalf of the Company. By: Name: ▇▇▇▇▇▇ ▇▇▇▇▇▇ Title: President {JK00876051.1 }12 EXECUTION BY ANY SUBSCRIBER WHICH IS AN ENTITY (Corporation, Partnership, LLC, Trust, Etc.) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Name of Entity (Please Print) Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009201___, on behalf of the Company. By: _________________________________ Name: :▇▇▇▇▇▇ ▇▇▇▇▇▇ Title: o President {JK00876051.1 }13 SUBSCRIBER QUESTIONNAIRE - ALL SUBSCRIBERS MUST COMPLETE APPLICABLE PORTIONS INSTRUCTIONS: IF YOU ARE AN ACCREDITED INVESTOR, please check all boxes below which correctly describe you. If you cannot check any of these boxes, complete the representations below regarding your qualification to invest in this Offering, as well as all other information required. [] You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o [] You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o [] You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o [] You are a director or executive officer of KeyOn Communications, Inc. o the Company. [] You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding your principal residence) at the time of your subscription for and purchase of the UnitsShares. o [] You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o [] You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o [] You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsIF YOU HAVE NOT CHECKED ONE OF THE BOXES ABOVE, yourYOUR INITIALS ARE REQUIRED BELOW: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand represent that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able the purchase price, together with any other amounts previously used to evaluate the risks and merits of an investment purchase Shares in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control Offering, does not exceed 10% of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as greater of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of PurchaserSubscriber’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually annual income or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:net
Appears in 1 contract
Sources: Common Stock Subscription Agreement
Telephone Number Telephone Number. Fax Number (if available) _________________________________ Fax Number (if available) _________________________________ E-Mail (if available) _________________________________ E-Mail (if available) __________________________________ (Signature) _________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092006, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: _______________________________________________________ State of Principal Office: __________________________________________________________________ Federal Taxpayer Identification Number: ______________________________________________________ ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092006, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities with total assets in excess of $5,000,000. o You are a director or executive officer of KeyOn CommunicationsAvasoft, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and Shares, whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in Shares of the UnitsCompany, your: Investment Objectives: x S Aggressive Growth x S Speculation Risk Tolerance: o S Low Risk o £ Moderate Risk x S High Risk Are you associated with a NASD Member Firm? o £ Yes o £ No ____ ____ I/We have received a copy of the offering Memorandum. ____ ____ I/We have reviewed the risk sections of the offering documents. ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We meet the suitability standards listed in the offering Memorandum. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber undersigned hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased Shares of the UnitsCompany. ___________________________________________ Name of Purchaser [please print] ___________________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________________ Name of Signatory (Entities only) ___________________________________________ Title of Signatory (Entities only) ___________________________________________ Name of Co-Purchaser [please print] ___________________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092014, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address __ ___________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this [____ ] day of [__________ 2009] 2014, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)Shares, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. __ __________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) __ __________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092011, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092011, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (American Strategic Minerals Corp)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092012, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092012, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092013, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092013, on behalf of the Company. By: _________________________________ Name: Title: o ¨ You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o ¨ You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o ¨ You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o ¨ You are a director or executive officer of KeyOn Communications, Inc. o the Company. ¨ You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o ¨ You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o ¨ You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o ¨ You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x ¨ Aggressive Growth x ¨ Speculation Risk Tolerance: o ¨ Low Risk o ¨ Moderate Risk x ¨ High Risk Are you associated with a NASD FINRA Member Firm? o ¨ Yes o ¨ No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092013, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ___________-_________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) ___________ _______________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092013, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x [ ] Aggressive Growth x [ ] Speculation Risk Tolerance: o [ ] Low Risk o [ ] Moderate Risk x [ ] High Risk Are you associated with a NASD FINRA Member Firm? o [ ] Yes o [ ] No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ ----------------------------------- ----------------------------------- E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ ----------------------------------- ----------------------------------- (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092005, on behalf of the CompanyPubco. By: _________________________________ Name: Title: By: ________________________________ Name: Title: C-11 EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY ------------------------------------------ (Corporation, Partnership, Trust, Etc.) -------------------------------------------------------------------------------- Name of Entity (Please Print) Date of Incorporation or Organization: :__________________________________________ State of Principal Office: :______________________________________________________ Federal Taxpayer Identification Number: :_________________________________________ ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] _________________________________ Attest: :__________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092005, on behalf of the CompanyPubco. By: __:_______________________________ Name: Title: o INVESTOR QUESTIONNAIRE INSTRUCTIONS: CHECK ALL BOXES BELOW WHICH CORRECTLY DESCRIBE YOU. |_| You are (iI) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”"SECURITIES ACT"), (iiII) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iiiIII) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”"EXCHANGE ACT"), (ivIV) an insurance company as defined in Section 2(13) of the Securities Act, (vV) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”"INVESTMENT COMPANY ACT"), (viVI) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (viiVII) 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, as amended, (viiiVIII) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ixIX) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“"ERISA”") and (1) the decision that you shall subscribe for and purchase units consisting of one (1) share of Series A Convertible Preferred Stock and a three-year detachable warrant to purchase shares of common stock and warrants to purchase common stock (the “"Units”"), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Units is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation "REGULATION D”") or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o |_| You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o |_| You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”"CODE"), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities with total assets in excess of $5,000,000. o |_| You are a director or executive officer of KeyOn CommunicationsGlobalOptions Group, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:Inc.
Appears in 1 contract
Sources: Subscription Agreement (Creative Solutions With Art, Inc.)
Telephone Number Telephone Number. Fax Number (if available) _____Fax Number (if available) ▇▇▇▇@▇▇▇▇▇▇▇.▇▇▇ E-Mail E-Mail (if available) /s/ ▇▇▇▇▇ ▇. ▇▇▇▇ ▇▇. (Signature) (Signature of Additional Purchaser) ACCEPTED this 1st day of June, 2018, on behalf of the Company. By: /s/ ▇▇▇▇▇ ▇▇▇▇▇▇ Chief Operating Officer Date of Incorporation or Organization: ___________________________ Fax Number (if available) State of Principal Office: _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) _______Federal Taxpayer Identification Number: _________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this _______ day of _______________ 20092018, on behalf of the Company. By: _________________________________ Name: Title: o You are Chief Operating Officer ☐ I am a (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)Shares, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are ☐ I am a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are ☐ I am an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase . ☒ I am a director or executive officer of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high riskCompany.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (EVO Transportation & Energy Services, Inc.)
Telephone Number Telephone Number. Fax Number (if available) _________________________________ Fax Number (if available) _________________________________ E-Mail (if available) _________________________________ E-Mail (if available) __________________________________ (Signature) _________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092012, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092012, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “UnitsShares”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092013, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092013, on behalf of the Company. By: _________________________________ Name: Title: o [ ] You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)Shares, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares is made solely by persons or entities that are accredited investors. o [ ] You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o [ ] You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares and its underlying securities in excess of $5,000,000. o [ ] You are a director or executive officer of KeyOn Communications, Inc. o the Company. [ ] You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsShares. o [ ] You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o [ ] You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares and whose subscription for and purchase of the Units Shares is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o [ ] You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsShares, your: Investment Objectives: x [ ] Aggressive Growth x [ ] Speculation Risk Tolerance: o [ ] Low Risk o [ ] Moderate Risk x [ ] High Risk Are you associated with a NASD FINRA Member Firm? o [ ] Yes o [ ] No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsShares. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser [SIGNATURE PAGE TO INVESTOR QUESTIONNAIRE AGREEMENT – ______________________________] I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
Appears in 1 contract
Sources: Subscription Agreement (Spherix Inc)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Name Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: o [ ] You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock (the “Shares”) and warrants to purchase shares of common stock (the “UnitsWarrants”, and, together with the Shares, the “Securities”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Securities is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Securities is made solely by persons or entities that are accredited investors. o [ ] You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o [ ] You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Securities and its underlying securities in excess of $5,000,000. o [ ] You are a director or executive officer of KeyOn Communications, Inc. o the Company. [ ] You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the UnitsSecurities (excluding principal residence). o [ ] You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o [ ] You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Securities and whose subscription for and purchase of the Units Securities is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o [ ] You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsSecurities, your: Investment Objectives: x [ ] Aggressive Growth x [ ] Speculation Risk Tolerance: o [ ] Low Risk o [ ] Moderate Risk x [ ] High Risk Are you associated with a NASD FINRA Member Firm? o [ ] Yes o [ ] No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:)
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Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092017, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092017, on behalf of the Company. By: _________________________________ Name: Title: o CONFIDENTIAL INVESTOR QUESTIONNAIRE FOR “ACCREDITED INVESTORS” Instructions: Check all boxes below which correctly describe you. [ ] You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)Shares, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Securities is made solely by persons or entities that are accredited investors. o [ ] You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o [ ] You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Securities and its underlying securities in excess of $5,000,000. o [ ] You are a director or executive officer of KeyOn Communications, Inc. o the Company. [ ] You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the UnitsSecurities. o [ ] You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o [ ] You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Securities and whose subscription for and purchase of the Units Securities is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o [ ] You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the UnitsSecurities, your: Investment Objectives: x [ ] Aggressive Growth x [ ] Speculation Risk Tolerance: o [ ] Low Risk o [ ] Moderate Risk x [ ] High Risk Are you associated with a NASD FINRA Member Firm? o [ ] Yes o [ ] No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the UnitsSecurities. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs The Subscriber represents and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledgewarrants as follows:
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Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092007, on behalf of the Company. By: _________________________________ Name: Title: Instructions: Check all boxes below which correctly describe you. o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares Units is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities with total assets in excess of $5,000,000. o You are a director or executive officer of KeyOn CommunicationsSurfect Holdings, Inc. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and Units, whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. Check all boxes below which correctly describe you. With respect to this investment in Units of the UnitsCompany, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No Your initials (purchaser and co-purchaser, if applicable) are required for each item below: ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased Units of the UnitsCompany. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:
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Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional PurchaserSubscriber) ACCEPTED this ___ day of _________ 20092012, on behalf of the Company. By: :_________________________________ Name: Title: Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 20092012, on behalf of the Company. By: _________________________________ Name: Title: o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”), is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 (excluding residence) at the time of your subscription for and purchase of the Units. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units and whose subscription for and purchase of the Units is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment in the Units, your: Investment Objectives: x p Aggressive Growth x p Speculation Risk Tolerance: o Low Risk o Moderate Risk x p High Risk Are you associated with a NASD FINRA Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser Subscriber [please print] ___________________________________ Signature of Purchaser Subscriber (Entities please provide signature of PurchaserSubscriber’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser Co- Subscriber [please print] ___________________________________ Signature of CoCo- Subscriber Citibank 6▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇ A/C of Sichenzia R▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP A/C#: 92883436 ABA#: 0▇▇▇▇▇▇▇▇ SWIFT Code: C▇▇▇▇▇▇▇ Ref: B▇▇▇▇▇▇▇ GOLD CORP. THIS ESCROW AGREEMENT (this “Agreement”) is made as of ___ __, 2012, by and among BULLFROG GOLD CORP., a Delaware corporation, with an address at 8▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (“Bullfrog”), and Sichenzia R▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP, with an address at 6▇ ▇▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇ (the “Escrow Agent”). Capitalized terms used but not defined herein shall have the meanings set forth in that certain form of Subscription Agreement, annexed hereto as Schedule I, as amended or supplemented from time-Purchaser I state that I am familiar with to-time, including all attachments, schedules and exhibits thereto (the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledge:“Subscription Agreement”).
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Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 20092011, on behalf of the Company. By: :_________________________________ Name: ▇▇▇▇▇ ▇▇▇▇▇▇ Title: Chief Executive Officer Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, 2011, on behalf of the Company. By: _________________________________ Name: ▇▇▇▇▇ ▇▇▇▇▇▇ Title: Chief Executive Officer o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) 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, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and (1) the decision that you shall subscribe for and purchase shares of common stock and warrants to purchase common stock (the “Units”)stock, is made by a plan fiduciary, as defined in Section 3(21) of ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or (2) you have total assets in excess of $5,000,000 and the decision that you shall subscribe for and purchase the Shares is made solely by persons or entities that are accredited investors, as defined in Rule 501 of Regulation D promulgated under the Securities Act (“Regulation D”) or (3) you are a self-directed plan and the decision that you shall subscribe for and purchase the Units Shares of Common Stock is made solely by persons or entities that are accredited investors. o You are a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended. o You are an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), a corporation, Massachusetts or similar business trust or a partnership, in each case not formed for the specific purpose of making an investment in the Units Shares of Common Stock and its underlying securities in excess of $5,000,000. o You are a director or executive officer of KeyOn Communications, Inc. the Company. o You are a natural person whose individual net worth, or joint net worth with your spouse, exceeds $1,000,000 at the time (exclusive of residence) of your subscription for and purchase of the UnitsShares of Common Stock. o You are a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of the two most recent years, and who has a reasonable expectation of reaching the same income level in the current year. o You are a trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units Shares of Common Stock and whose subscription for and purchase of the Units Shares of Common Stock is directed by a sophisticated person as described in Rule 506(b)(2)(ii) of Regulation D. o You are an entity in which all of the equity owners are persons or entities described in one of the preceding paragraphs. With respect to this investment o You are a non-U.S. Person (a “Reg S Person”), and as such Reg S Person, you hereby represent that the representations contained in the Units, your: Investment Objectives: x Aggressive Growth x Speculation Risk Tolerance: o Low Risk o Moderate Risk x High Risk Are you associated with a NASD Member Firm? o Yes o No ____ ____ I/We understand that this investment is not guaranteed. ____ ____ I/We are aware that this investment is not liquid. ____ ____ I/We are sophisticated in financial and business affairs and are able to evaluate the risks and merits of an investment in this offering. ____ ____ I/We confirm that this investment is considered “high risk.” paragraphs (This type of investment is considered high risk due to the inherent risks including lack of liquidity and lack of diversification. Success or failure of private placements such as this is dependent on the corporate issuer of these securities and is outside the control of the investors. While potential loss is limited to the amount invested, such loss is possible.1) The Subscriber hereby represents and warrants that all of its answers to this Investor Questionnaire through (7) below are true as of the date of its execution of the Subscription Agreement pursuant to which it purchased the Units. ___________________________________ Name of Purchaser [please print] ___________________________________ Signature of Purchaser (Entities please provide signature of Purchaser’s duly authorized signatory.) ___________________________________ Name of Signatory (Entities only) ___________________________________ Title of Signatory (Entities only) ___________________________________ Name of Co-Purchaser [please print] ___________________________________ Signature of Co-Purchaser I state that I am familiar with the financial affairs and investment objectives of the investor named above and reasonably believe that a purchase of the securities is a suitable investment for this investor and that the investor, either individually or together with his or her purchaser representative, understands the terms of and is able to evaluate the merits of this offering. I acknowledgecorrect:
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