Confidential Purchaser Questionnaire. INSTRUCTIONS: This Purchaser Questionnaire (this “Questionnaire”) is to be completed and executed by prospective investors interested in purchasing common shares of Vsurance, Inc., a Nevada corporation (the “Company”). The Shares being offered are sometimes hereinafter referred to as the “Securities.” Purchasers must meet, among others, certain standards imposed by Regulation D as adopted by the Securities and Exchange Commission under the Securities Act of 1933, as amended (the “Securities Act”), because neither the Securities nor the shares of Common Stock underlying the Securities have been registered under the Securities Act, and are being sold in reliance upon the exemption provided by Section 4(2) of the Securities Act and/or Rule 506 promulgated thereunder. The undersigned acknowledges and agrees that the Company is relying on the undersigned’s representations contained in this Questionnaire and the related subscription documents in determining whether to accept the subscription. The Company reserves the right to request additional information, financial or otherwise, from potential investors if necessary for verification purposes. A response should be provided to each and every question. If the answer to any question is “none” or “not applicable,” please so indicate. Your answers will, at all times, be kept strictly confidential; however, everyone who agrees to purchase Securities hereby agrees that the Company may present this Questionnaire to such parties as necessary in order to assure itself that the offer and sale of Securities to you will not result in a loss of the exemption from registration under the Securities Act, which is being relied upon by the Company in connection with the sale of the Securities. Investors investing as: Individual Investors should complete the Individual Purchaser Questionnaire beginning on page A-1. Trusts should complete the Trust Questionnaire beginning on page B-1. Partnerships should complete the Partnership Questionnaire beginning on page C-1. Corporations should complete the Corporation Questionnaire beginning on page D-1. Limited Liability Companies should complete the Limited Liability Company Questionnaire beginning on page E-1. IMPORTANT: Please Complete Investor Name: INDIVIDUAL PURCHASER QUESTIONNAIRE Vsurance, Inc. Vsurance, Inc. The information contained in this Questionnaire is being furnished in order to determine whether the undersigned’s subscription to purchase the Securities of Vsurance, Inc. may be accepted. All information contained in this Questionnaire will be treated confidentially. The undersigned understands, however, that the Company may present this Questionnaire to such parties as it deems appropriate if called upon to establish that the proposed offer and sale of the Securities is exempt from registration under the Securities Act of 1933, as amended, or meets the requirements of applicable state securities or “blue sky” laws. Further, the undersigned understands that the offering is required to be reported to the Securities and Exchange Commission and to various state securities or “blue sky” regulators. If you are purchasing Securities with your spouse, you must both sign the Signature Page (page A-5). If you are purchasing Securities with another person NOT your spouse, you must each fill out a separate Questionnaire. Please make a photocopy of pages A-1 to A-5 and return both completed Questionnaires to the Company in the same envelope.
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Samples: Subscription Agreement (Vsurance), Subscription Agreement (Vsurance), Securities Purchase Agreement (Vsurance)
Confidential Purchaser Questionnaire. INSTRUCTIONSGentlemen: This The information contained in this Confidential Purchaser Questionnaire (this the “Questionnaire”) is being furnished to be completed and executed by prospective investors interested in purchasing common shares of Vsurance, Inc.IntelGenx Technologies Corp., a Nevada Delaware corporation (the “CompanyCorporation”). The Shares being offered are sometimes hereinafter referred , to as enable the Corporation to determine whether offers and sales of the Corporation’s Units (the “Securities.” Purchasers must meet, among others, certain standards imposed by Units”) may be made to the undersigned under (i) Regulation D as adopted by the Securities and Exchange Commission promulgated under the Securities Act of 1933, as amended (the “Securities Act”), because neither ; (ii) any other exemption from the Securities nor the shares registration provisions of Common Stock underlying the Securities have been registered under the Securities Act, ; and are being sold in reliance upon the exemption provided by Section 4(2(iii) exemptions from applicable registration provisions of the Securities Act and/or Rule 506 promulgated thereunderstate securities laws. The undersigned acknowledges and agrees understands that the Company is relying on Corporation will rely upon the undersigned’s representations information contained in herein for purposes of such determination. In addition, this Questionnaire and information will be used by the related subscription documents Corporation in determining whether to accept the subscriptionundersigned's subscription for Units. The Company reserves undersigned represents to the right Corporation that (i) the information contained herein is complete and accurate and may be relied upon by the Corporation and its counsel; and (ii) that the undersigned will notify the Corporation immediately of any material change in any of such information occurring prior to request additional informationclosing of the purchase of any of the Units by the undersigned. The undersigned further represents to the Corporation that (a) the undersigned understands none of the Units have not been registered under the Securities Act or applicable state securities laws, financial and are being offered in reliance upon the exemptions from the registration requirements of the Securities Act and such state securities laws; (b) the undersigned is acquiring the Units for the undersigned's own account and not for the account of any other person, and such purchase is not being made with a view to the further resale or otherwisedistribution thereof; and (c) the undersigned understands that the completion of this Questionnaire does not constitute an offer of the Units to the undersigned. The undersigned understands that if the undersigned does not purchase the Units or if the Corporation does not offer the Units to the undersigned subsequent to submitting this Questionnaire, from potential investors if necessary the undersigned may be asked to return all documents submitted to the undersigned in connection with the proposed purchase of the Units. All information contained herein is for verification purposes. A response should be provided to each the Corporation's use and every question. If the answer to any question is “none” or “not applicable,” please so indicate. Your answers will, its counsel's use and will at all times, times be kept strictly confidential; however, everyone who agrees to purchase Securities hereby the undersigned agrees that the Company may present this Questionnaire to such parties as necessary in order to assure itself that the offer and sale of Securities to you will not result in a loss of the exemption from registration under the Securities Act, which is being relied upon by the Company in connection with the sale of the Securities. Investors investing as: Individual Investors should complete the Individual Purchaser Questionnaire beginning on page A-1. Trusts should complete the Trust Questionnaire beginning on page B-1. Partnerships should complete the Partnership Questionnaire beginning on page C-1. Corporations should complete the Corporation Questionnaire beginning on page D-1. Limited Liability Companies should complete the Limited Liability Company Questionnaire beginning on page E-1. IMPORTANT: Please Complete Investor Name: INDIVIDUAL PURCHASER QUESTIONNAIRE Vsurance, Inc. Vsurance, Inc. The information contained in this Questionnaire is being furnished in order to determine whether the undersigned’s subscription to purchase the Securities of Vsurance, Inc. may be accepted. All information contained in this Questionnaire will be treated confidentially. The undersigned understands, however, that the Company may present this Questionnaire to such parties as it deems appropriate may deem appropriate, if called upon to establish that the proposed offer and sale availability of the Securities is exempt from registration exemptions under the Securities Act of 1933, as amended, or meets the requirements of and applicable state securities or “blue sky” laws. FurtherFurthermore, the undersigned understands agrees that the offering is required Corporation may disclose certain information contained herein to any state or federal securities agency or regulatory authority as may be reported necessary or appropriate to comply with the Securities and Exchange Commission and to various Act or any state securities laws, and any rules or “blue sky” regulatorsregulations promulgated thereunder. If you are purchasing Securities with your spouse, you must both sign the Signature Page (page A-5). undersigned is an individual: By:_______________________________________ Print Name: ________________________________ Date: _____________________________________ If you are purchasing Securities with another person NOT your spouse, you must each fill out a separate Questionnaire. Please make a photocopy of pages A-1 to A-5 and return both completed Questionnaires to the Company in the same envelope.undersigned is an entity: By:_______________________________________ Title: _____________________________________ Print Name: ________________________________ Date: _____________________________________
Appears in 1 contract
Samples: Subscription Agreement (IntelGenx Technologies Corp.)
Confidential Purchaser Questionnaire. INSTRUCTIONS: This Purchaser Questionnaire (this “Questionnaire”) is to be completed and executed by prospective investors interested in purchasing common shares of Vsurance, Inc., a Nevada corporation (the “Company”). The Shares being offered are sometimes hereinafter referred to as the “Securities.” Purchasers must meet, among others, certain standards imposed by Regulation D as adopted by the Securities and Exchange Commission under the Securities Act of 1933, as amended (the “Securities Act”), because neither the Securities nor the shares of Common Stock underlying the Securities have been registered under the Securities Act, and are being sold in reliance upon the exemption provided by Section 4(2) of the Securities Act and/or Rule 506 promulgated thereunder. The undersigned acknowledges and agrees that the Company is relying on the undersigned’s representations contained in this Questionnaire and the related subscription documents in determining whether to accept the subscription. The Company reserves the right to request additional information, financial or otherwise, from potential investors if necessary for verification purposes. A response should be provided to each and every question. If the answer to any question is “none” or “not applicable,” please so indicate. Your answers will, at all times, be kept strictly confidential; however, everyone who agrees to purchase Securities hereby agrees that the Company may present this Questionnaire to such parties as necessary in order to assure itself that the offer and sale of Securities to you will not result in a loss of the exemption from registration under the Securities Act, which is being relied upon by the Company in connection with the sale of the Securities. Investors investing as: Individual Investors should complete the Individual Purchaser Questionnaire beginning on page A-1. Trusts should complete the Trust Questionnaire beginning on page B-1. Partnerships should complete the Partnership Questionnaire beginning on page C-1. Corporations should complete the Corporation Questionnaire beginning on page D-1. Limited Liability Companies should complete the Limited Liability Company Questionnaire beginning on page E-1. IMPORTANT: Please Complete Investor Name: INDIVIDUAL PURCHASER QUESTIONNAIRE Vsurance, Inc. Vsurance, Inc. The information contained in this Questionnaire is being furnished in order to determine whether the undersigned’s subscription to purchase the Securities of Vsurance, Inc. may be accepted. All information contained in this Questionnaire will be treated confidentially. The undersigned understands, however, that the Company may present this Questionnaire to such parties as it deems appropriate if called upon to establish that the proposed offer and sale of the Securities is exempt from registration under the Securities Act of 1933, as amended, or meets the requirements of applicable state securities or “blue sky” laws. Further, the undersigned understands that the offering is required to be reported to the Securities and Exchange Commission and to various state securities or “blue sky” regulators. If you are purchasing Securities with your spouse, you must both sign the Signature Page (page A-5). If you are purchasing Securities with another person NOT your spouse, you must each fill out a separate Questionnaire. Please make a photocopy of pages A-1 to A-5 and return both completed Questionnaires to the Company in the same envelope.
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