EX-10
from 10-Q
12 pages
Subject and Pursuant to the Attached “Terms and Conditions” of This Subscription Agreement, Including All Schedules and Appendices Attached Hereto, the Subscriber Hereby Irrevocably Subscribes For, and on the Closing Date, Will Purchase From the Company, the Following Securities at the Following Price: Shares US$ Per Shares for a Total Purchase Price of US$ the Subscriber Owns, Directly or Indirectly, the Following Securities of the Company: [Check if Applicable] the Subscriber Is ¨ an Affiliate of the Company the Subscriber Directs the Company to Issue, Register and Deliver the Certificates Representing the Shares as Follows: Registration Instructions Delivery Instructions Name to Appear on Certificate Name and Account Reference, if Applicable Account Reference if Applicable Contact Name Address Address Tax I.D./E.I.N./S.S.N. Telephone Number Executed by the Subscriber This Day of , 2015
12/34/56