SIGNATURE PAGE FOR INDIVIDUAL INVESTORS
SIGNATURE PAGE
FOR INDIVIDUAL INVESTORS
Total Shares subscribed: _________ Aggregate Purchase Price: $_____________
INVESTOR: INVESTOR:
__________________________ __________________________
Signature Signature
___________________________ ___________________________
Print or Type Name Print or Type Name
___________________________ ___________________________
Social Security Number Social Security Number
Residence Address Residence Address
___________________________ ___________________________
___________________________ ___________________________
_____________________________ _____________________________
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SUBSCRIPTION AGREEMENT
SIGNATURE PAGE
FOR TRUST INVESTORS
Total Shares subscribed: _________ $_______________
Name(s) of Investor Representatives
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
_______________________________________________________________________________________________
Name of Trust (Please print or type)
_______________________________________________________________________________________________
Name of Trustee (Please print or type)
_______________________________________________________________________________________________
Date Trust was formed
By_____________________________________________________________________________________________
Trustee’s Signature
Taxpayer Identification Number ____________________
Trustee’s Address: ________________________________________
________________________________________
________________________________________
Attention: ________________________________
Executed at ________ _____________, this day of ______ 20_______
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SUBSCRIPTION AGREEMENT
SIGNATURE PAGE
FOR PARTNERSHIP INVESTORS
Total Shares subscribed: _________ $_______________
Name(s) of Investor Representatives
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
_______________________________________________________________________________________________
Name of Partnership (Please print or type)
_______________________________________________________________________________________________
Signature of General Partner (Please print or type)
_______________________________________________________________________________________________
Signature of Additional General Partner
(If required by partnership agreement)
_______________________________________________________________________________________________
Signature of Additional General Partner
(If required by partnership agreement)
Taxpayer Identification Number _______________
Partnership Address: ________________________________________
________________________________________
________________________________________
Attention: _________________________________
Executed at ________ _____________, this day of ______ 20_________
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SUBSCRIPTION AGREEMENT
SIGNATURE PAGE
FOR CORPORATE INVESTORS
Total Shares subscribed: _________ $_______________
Name(s) of Investor Representatives
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
______________________________ ______________________________
Name Address
_______________________________________________________________________________________________
Name of Corporation (Please print or type)
By_____________________________________________________________________________________________
Signature of Authorized Agent
Taxpayer Identification Number _______________
Corporation Address: ________________________________________
________________________________________
________________________________________
Attention: ________________________________
Executed at ________ _____________, this day of ______ 20________
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PURCHASER QUESTIONNAIRE
VYRIAN INC.
00000 Xxxxxxxxx Xxxxxxx, Xxxxx 000
Houston, TX 77074
Gentlemen:
I hereby furnish the information contained below to the Company so that it may determine whether I am a suitable investor in the Company's offering of Common Stock. I understand that the information is needed for you to determine whether you have reasonable grounds to believe that I am an “Accredited Investor” as that term is defined in Regulation D promulgated under the Act, in accordance with the suitability standards established by the Company and that I have such knowledge and experience in financial and business matters that I am capable of evaluating the merits and risks of the proposed investment in the Company.
I understand that (a) you will rely on the information contained herein for purposes of such determination, (b) the Securities will not be registered under the Act, (c) the Securities will not be registered under securities laws of any state in reliance upon similar exemptions, and (d) this questionnaire is not an offer to the purchase any Securities.
The Company and its agents, employees or representatives, will keep information contained in this questionnaire confidential. I understand, however, that the Company may have the need to present it to such parties, as it deems advisable in order to establish the applicability under any federal or state securities laws of an exemption from registration.
In accordance with the foregoing, the following representations and information are hereby made and furnished:
Please answer all questions. If the answer is “none” or “not applicable,” please so state.
INFORMATION REQUIRED OF EACH PROSPECTIVE INVESTOR:
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1.
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Name: ________________________________________ Age:____________________
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2.
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Social Security Number: _______________ No. Of Dependents: __________________
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3.
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Marital Status __________________ Citizenship: ______________________________
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4.
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Residence Address and Telephone Number ___________________________________
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______________________________________________________________________
5. State in which you are: licensed to drive? ____________________________________
Registered to vote? ____________________________________________
File income tax returns? ________________________________________
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6. Employer and Position ___________________________________________________
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7.
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Business Address and Telephone Number: __________________________________
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_____________________________________________________________________
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8.
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Business or professional education and the degrees received are as follows:
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School: _______________________________________________________________
Degree: ______________________________________________________________
Year Received: _________________________________________________________
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9.
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Please select, which applies to you ( choose one)
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(a)
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Individual income during 2009 (exclusive of spouse’s income)
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(b)
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Individual income during 2010 (exclusive of spouse’s income)
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(c)
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Estimated income during 2011 (exclusive of spouse’s income)
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________ $ 50,000-$100,000
________ $100,000-$200,000
________ Over $200,000
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(d)
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Joint income, with spouse, during 2009:
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(e)
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Joint income, with spouse, during 2010:
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(f)
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Estimated joint income, with spouse, for 2011:
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_______ $100,000-$300,000
_______ Over $300,000
(g) _______ A charitable organization, corporation, or partnership with assets exceeding
$5,000,000.
(h) _______ A trust with assets in excess of $5,000,000, not formed to acquire the securities
Offered, whose purchases a sophisticated person makes.
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10.
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Estimated net worth (may include joint net worth with spouse)
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_______ Over $1,000,000
The term “net worth” means the excess of total assets over total liabilities. In computing net worth, the principal residence of the investor must be valued at cost, including costs of improvements, or at recently appraised value by an institutional lender making a secured loan.
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11.
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Are you involved in any litigation, which, if an adverse decision occurred, would materially affect your financial condition? Yes__ No_____. If yes, please provide details:
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__________________________________________________________
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12.
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I consider myself to be an experienced and sophisticated investor or am advised by a qualified investment advisor, all as required under the various securities laws and regulations:
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Yes___ No___
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13.
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I understand the full nature and risk of an investment in the Securities, and I can afford the complete loss of my entire investment: Yes___ No___
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14.
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I am able to bear the economic risk of an investment in the Securities for an indefinite period of time and understand that an investment in the Securities may be illiquid:
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Yes___ No___
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15.
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I further understand that should I purchase the Securities, I be required to agree not to dispose of the Securities except in compliance with the conditions contained in the accompanying Subscription Agreement: Yes___ No___
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16. Have you participated in other private placement securities? Yes___ No___
I understand that the Company will be relying on the accuracy and completeness of my responses to the foregoing questions and I represent and warrant to the Company as follows:
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(i)
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The answers to the above questions are complete and correct and may be relied upon by the Company whether the offering in which I propose to participate is exempt from registration under the Act and the securities laws of certain states;
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(ii)
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I will notify the Company immediately of any material change in any statement made herein occurring prior to the closing of any purchase by me of an interest in the Company; and
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(iii)
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I have sufficient knowledge and experience in financial and business matters to evaluate the merits and risks of the prospective investment; I am able to bear the economic risk of the investment and currently could afford a complete loss of such investment.
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IN WITNESS WHEREOF, I have executed this Purchaser Questionnaire this ____ day of ______, 20__, and declare that it is truthful and correct to the best of my knowledge.
| Signature of Prospective Investor | Signature of Prospective Investor | ||
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