Exhibit No. 99.2
SimplaGene USA, Inc.
Form SB-2, Amendment No. 1
SIMPLAGENE USA, INC. - COMMON STOCK
Subscription Agreement
I/we desire to purchase _________________________ shares of SimplaGene USA, Inc.
at $0.10 per share for a total of $_________________________.
Make Checks Payable to: Associated Bank Minnesota, NA, SimplaGene USA,
Escrow Account
Subscriber Information - Please clearly print name(s) in which Shares are to be
acquired. All correspondence will go to the Investor Residence Address.
Investor 1 (First, Middle I., Last): Tax ID or Social
Security No.:
___________________________________________ __________________________
Investor 2 (First, Middle I. Last): Tax ID or Social
Security No.:
___________________________________________ __________________________
Registration For The Investment (how the investment should be titled):
_______________________________________________________
Investor Residence Address: Check One Of The Following:
_______________________________________ [ ] U.S. Citizen
Street [ ] Resident Alien
[ ] Foreign Resident, Country ___*
_______________________________________ [ ] U.S. Citizen residing outside U.S.
City, State ZIP Code
Form of Ownership (Individual, Joint, XXX, Trust, etc.)
_________________________________________________________
Subscriber Signature: The undersigned has the authority to enter into this
subscription agreement on behalf of the person(s) or entity registered above.
__________________________________________ Date:___________________________
Authorized Signature of Investor 1
__________________________________________ Date:___________________________
Authorized Signature of Investor 2
* If you are a resident of a foreign country, please also complete and
return Form W-8BEN, which we will provide to you.
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