000-52315
(Commission File Number)
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20-1915083
(IRS Employer Identification No.)
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2301 Dupont Drive, Suite 525
Irvine, CA 92612
(Address of Principal Executive Offices and zip code)
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Item 1.01. | Entry into a Material Definitive Agreement. |
Item 3.02.
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Unregistered Sales of Equity Securities.
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(d)
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Exhibits.
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10.1
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Form of Subscription Agreement.
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10.2
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Form of Common Stock Purchase Warrant.
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AtheroNova Inc.
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Date: October 5, 2012 |
By:
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/s/ Mark Selawski | |
Mark Selawski
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Chief Financial Officer & Secretary
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1.
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The subscription terms set forth herein (this “Subscription Agreement”) are made as of the date set forth below between AtheroNova Inc., a Delaware corporation (the “Company”), and the Investor.
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2.
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As of the Closing (as defined below) and subject to the terms and conditions hereof, the Company and the Investor agree that the Investor will purchase from the Company and the Company will issue and sell to the Investor in the aggregate that number of Units consisting of 1 share of Common Stock of the Company, par value $0.0001 per share (the “Common Stock”) and a warrant to purchase .50 shares of Common Stock at $.625 per share. The warrant is exercisable for four (4) years from the date of issuance of the Common Stock purchased. The per Unit purchase price is $0.50 (the “Offering Price”), pursuant to an offering (the “Offering”) to one or more potential investors. The Units are also sometimes referred to herein as the “Securities”), as is set forth on the signature page hereto (the “Signature Page”). The Investor acknowledges that the offering is not a firm commitment underwriting and that the Closing will not occur unless the Company has received Subscription Agreements for Shares in the aggregate purchase amount of at least $2,500,000.
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3.
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The completion of the purchase and sale of the Units shall occur at one or more closings (each a “Closing”) which, in accordance with Rule 15c6-1 promulgated under the Securities Exchange Act of 1934, as amended (the “Exchange Act”), are expected to occur from and after the date of receipt hereof through September 7, 2012. At a Closing, (a) the Company shall cause the Escrow Agent (as defined below) to release to the Investor the Units being purchased by the Investor, and (b) the aggregate purchase price for the Units being purchased by the Investor, less certain fees and expenses to be paid on behalf of the Company, will be delivered by or on behalf of the Investor to the Company.
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a.
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Delivery of Funds. No later than one (1) business day after the execution of this Agreement by the Investor and the Company, the Investor shall remit by wire transfer the amount of funds equal to the aggregate purchase price for the Units being purchased by the Investor to the following account (the “Escrow Account”) designated by the Company and the Philadelphia Brokerage Corporation, as placement agent (the “Placement Agent”), pursuant to the terms of that certain Escrow Agreement (the “Escrow Agreement”) dated as of June 19, 2012 by and among the Company, the Placement Agent and Bryn Mawr Trust Company (the “Escrow Agent”):
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b.
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Delivery of Units. At least one (1) business day prior to the Closing, the Company shall deliver to the Escrow Agent certificates representing the Shares as well as Warrants represented in each Investor’s documents. On the day of the Closing, the Escrow Agent shall deliver the certificates and documents representing the Shares and Warrants to the Investor by overnight courier to the address designated by the Investor on the signature page of this Subscription Agreement.
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4.
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The offering and sale of the Units are being made pursuant to the Offering Memorandum (as defined below). The Investor acknowledges that the Company intends to enter into subscriptions, which the Company represents will be in substantially the same form as this Subscription Agreement, with certain other investors and intends to offer and sell (the “Offering”) Units with a minimum aggregate offering price of $2,500,000 and a maximum aggregate offering price of up to $5,000,000 pursuant to the Offering Memorandum. The Company may accept or reject this Subscription Agreement or any one or more other subscriptions with other investors in its sole discretion.
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5.
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The Company has entered into an engagement letter, dated March 26, 2012, amended on June 28, 2012 and August 17, 2012 (the “Engagement Letter”) with Philadelphia Brokerage Corporation (the “Placement Agent”), which will act as the Company’s Placement Agent with respect to the Offering and receive a fee (the “Placement Fee”) in connection with the sale of the Units equal to eight percent (8.0%) of the aggregate offering price of the Units (not including warrants associated with each Unit), plus the issuance to the Placement Agent of an aggregate number of shares of Common Stock with a value, at the offering price hereunder, equal to two percent (2%) of the gross amount of the Offering. The Company will reimburse the Placement Agent for its out-of-pocket expenses and for the fees of its outside counsel, such fees not to exceed $40,000 in the aggregate.
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6.
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The obligations of the Company to complete the transactions contemplated by this Subscription Agreement shall be subject to the satisfaction of the following conditions:
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a.
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the acceptance by the Company of this Subscription Agreement (as may be indicated by the Company’s execution of the Signature Page hereto);
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b.
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the receipt by the Company of the purchase price for the Units being purchased hereunder as set forth on the Signature Page; and
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c.
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the accuracy of the representations and warranties made by the Investor and the fulfillment of those undertakings of the Investor to be fulfilled prior to the date of the applicable Closing (each a “Closing Date”).
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7.
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The Investor’s obligation to purchase the Shares shall be subject to the satisfaction of the following conditions:
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a.
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no action shall have been taken and no statute, rule, regulation or order shall have been enacted, adopted or issued by any governmental agency or body which would, as of the Closing Date, prevent the issuance or sale of the Units; and no injunction, restraining order or order of any other nature by any federal or state court of competent jurisdiction shall have been issued as of the Closing Date which would prevent the issuance or sale of the Units;
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b.
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subsequent to August 14, 2012, (i) neither the Company nor its subsidiary (“Subsidiary”) has sustained any material loss or interference with its business from fire, explosion, flood or other calamity, whether or not covered by insurance, or from any labor dispute or court or governmental action, order or decree, otherwise than as set forth in the Company’s periodic reports and other information filed with the Securities and Exchange Commission (the “Commission”), (ii) there has not been any change in the capital stock (other than a change in the number of outstanding shares of Common Stock due to the issuance of shares upon the exercise of outstanding options or warrants or the conversion of convertible indebtedness), or material change in the short-term debt or long-term debt (other than the existing senior secured notes and the purchase agreement relating thereto) of the Company or its Subsidiary or any material adverse change in the business, affairs, operations, properties, financial condition or results of operations of the Company and its Subsidiary taken as a whole, otherwise than as set forth in the Company’s previously filed periodic reports and other information filed with the Commission;
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c.
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each of the representations and warranties of the Company contained in Exhibit A attached hereto shall be true and correct when made and on and as of the Closing Date, as if made on such date (except that those representations and warranties that address matters only as of a particular date shall remain true and correct as of such date), and all covenants and agreements herein contained to be performed on the part of the Company and all conditions herein contained to be fulfilled or complied with by the Company at or prior to the Closing Date shall have been duly performed, fulfilled or complied with;
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d.
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the Placement Agent shall have received from Stubbs Alderton & Markiles, LLP, counsel to the Company, such counsel’s written opinion addressed to the Placement Agent and the Investor with respect to such matters as is customary in transactions such as the offering and reasonably satisfactory to the Placement Agent;
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e.
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the Placement Agent shall have received on the Closing Date a certificate, addressed to the Placement Agent and dated the Closing Date, of the chief executive officer and the chief financial officer of the Company to the effect that:
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(i)
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each of the representations, warranties and agreements of the Company in this Subscription Agreement were true and correct in all material respects when originally made and are true and correct in all material respects as of the Closing Date; and the Company has complied in all material respects with all agreements and satisfied all the conditions on its part required under this Subscription Agreement to be performed or satisfied at or prior to the Closing Date; and
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(ii)
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subsequent to August 14, 2012, (A) neither the Company nor any of its Subsidiary has sustained any material loss or interference with its business from fire, explosion, flood or other calamity, whether or not covered by insurance, or from any labor dispute or court or governmental action, order or decree, otherwise than as set forth in the Company’s periodic reports and other information filed with the Commission, and (B) there has not been any change in the capital stock (other than a change in the number of outstanding shares of Common Stock due to the issuance of shares upon the exercise of outstanding options or warrants or the conversion of convertible indebtedness), or material change in the short-term debt or long-term debt (other than the existing senior secured notes and the purchase agreement relating thereto) of the Company or its Subsidiary or any material adverse change in the business, affairs, operations, properties, financial condition or results of operations of the Company and its Subsidiary taken as a whole, otherwise than as set forth in the Company’s previously filed periodic reports and other information filed with the Commission;
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f.
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on the Closing Date, the Company shall have furnished to the Placement Agent a Secretary’s Certificate of the Company setting forth the Company’s certificate of incorporation, bylaws and resolutions of the Company’s board of directors;
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g.
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the Company shall have entered into the Subscription Agreements with the Investor and such other investors purchasing Units in the Offering for the sale by the Company of Units resulting in gross proceeds to the Company of at least $2,500,000, and such agreements shall be in full force and effect on the Closing Date;
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h.
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the Company shall have entered into the Escrow Agreement, and such agreement shall be in full force and effect on the Closing Date; and
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i.
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prior to the Closing Date, the Company shall have furnished to the Placement Agent such further information, certificates or documents as the Placement Agent shall have reasonably requested. All opinions, letters, evidence and certificates mentioned above or elsewhere in this Agreement shall be deemed to be in compliance with the provisions hereof only if they are in form and substance reasonably satisfactory to counsel for the Placement Agent.
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8.
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The Investor hereby makes the following representations, warranties and covenants to the Company:
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a.
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The Investor represents that (i) it has been provided with a copy of the Confidential Private Placement Memorandum dated July 2, 2012, and Supplement No.1 to the Confidential Private Placement Memorandum dated August 21, 2012, with respect to the material terms of the Offering, and the attachments thereto (collectively, the “Offering Memorandum”) and the Company has made available to the Investor periodic reports and other information filed by the Company with the Commission, prior to or in connection with its receipt of this Subscription Agreement, (ii) it is knowledgeable, sophisticated and experienced in making, and is qualified to make, decisions with respect to investments in securities representing an investment decision like that involved in the purchase of the Units, (iii) the Securities are being and will be acquired for investment for the Investor’s own account, and not as a nominee or agent and not with a view to the resale or distribution of all or any part of the Shares, and the Investor has no present intention of selling, granting any participation in, or otherwise distributing any of the Securities within the meaning of the Securities Act, and it does not have any agreement or understanding, directly or indirectly, with any person or entity to distribute any of the Units and (iv) the Investor is not purchasing the Securities as a result of any advertisement, article, notice or other communication regarding the Securities published in any newspaper, magazine or similar media or broadcast over television or radio or presented at any seminar or any other general solicitation or general advertisement.
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b.
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The Investor has the requisite corporate, limited liability company, partnership, trust or other entity, as applicable, power and authority to enter into this Subscription Agreement and to consummate the transactions contemplated hereby. The execution and delivery of this Subscription Agreement by the Investor and the consummation by it of the transactions contemplated hereunder have been duly authorized by all necessary action on the part of the Investor. This Subscription Agreement has been executed by the Investor and, when delivered in accordance with the terms hereof, will constitute a valid and binding obligation of the Investor enforceable against the Investor in accordance with its terms, except as enforceability may be limited by applicable bankruptcy, insolvency, reorganization, moratorium or similar laws affecting creditors’ and contracting parties’ rights generally, and except as enforceability may be subject to general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).
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c.
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The Investor understands that the Investor may be required to bear the economic risk of the Investor’s investment in the Company for an indefinite period of time. The Investor further understands that (i) neither the offering nor the sale of the Units has been registered under the Securities Act or any applicable state securities laws (“State Acts”) in reliance upon exemptions from the registration requirements of such laws, (ii) the Units must be held by him, her or it indefinitely unless the sale or transfer thereof is subsequently registered under the Securities Act and any applicable State Acts, or an exemption from such registration requirements is available, (iii) the Company is under no obligation to register any of the Units on the Investor’s behalf or to assist the Investor in complying with any exemption from registration, and (iv) the Company will rely upon the representations and warranties made by the Investor in this Subscription Agreement in order to establish such exemptions from the registration requirements of the Securities Act and any applicable State Acts.
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d.
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The Investor understands that nothing in this Subscription Agreement or any other materials presented to the Investor in connection with the purchase and sale of the Units constitutes legal, tax or investment advice. The Investor has consulted such legal, tax and investment advisors as it, in its sole discretion, has deemed necessary or appropriate in connection with its purchase of Units.
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e.
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Neither the Investor nor any person acting on behalf of, or pursuant to any understanding with or based upon any information received from, the Investor has, directly or indirectly, engaged in any transactions in the securities of the Company (including, without limitation, any Short Sales involving the Company’s securities) since the time that the Investor was first contacted by the Placement Agent or the Company with respect to the transactions contemplated hereby. “Short Sales” include, without limitation, all “short sales” as defined in Rule 200 promulgated under Regulation SHO under the Exchange Act, whether or not against the box, and all types of direct and indirect stock pledges, forward sale contracts, options, puts, calls, short sales, swaps, “put equivalent positions” (as defined in Rule 16a-1(h) under the Exchange Act) and similar arrangements (including on a total return basis), and sales and other transactions through non-U.S. broker dealers or foreign regulated brokers. The Investor covenants that neither it, nor any person acting on behalf of, or pursuant to any understanding with or based upon any information received from, the Investor will engage in any transactions in the securities of the Company (including Short Sales) prior to the time that the transactions contemplated by this Subscription Agreement are publicly disclosed.
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f.
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The Investor represents that, except as set forth below, (i) it has had no position, office or other material relationship within the past three years with the Company or persons known to it to be affiliates of the Company, (ii) it is not, and it has no direct or indirect affiliation or association with, any FINRA member or an Associated Person (as such term is defined under the NASD Membership and Registration Rules Section 1011) as of the date the Investor executes this Subscription Agreement, and (iii) neither it nor any group of investors (as identified in a public filing made with the Commission) of which it is a member, acquired, or obtained the right to acquire, 20% or more of the Common Stock (or securities convertible or exercisable for Common Stock) or the voting power of the Company on a post-transaction basis. Exceptions:
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g.
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The Investor, if outside the United States, will comply with all applicable laws and regulations in each foreign jurisdiction in which it purchases, offers, sells or delivers Shares or has in its possession or distributes any offering material, in all cases at its own expense.
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h.
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The Investor is either (i) an “accredited investor” as such term is defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), or (ii) a “qualified institutional buyer” as term is defined in Rule 144A(a) promulgated under the Securities Act. The Investor has completed the Investor Questionnaire immediately following the Signature Page to this Subscription Agreement and all information provided therein is true and correct.
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i.
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The Investor has reviewed information provided by the Company in connection with the decision to purchase the Securities, consisting of the Company’s publicly available filings with the Commission and the information contained therein. The Company has provided the Investor with all the information that the Investor has requested in connection with the decision to purchase the Units. The Investor further represents that the Investor has had an opportunity to ask questions and receive answers from the Company regarding the business, properties, prospects, and financial condition of the Company. All such questions have been answered to the full satisfaction of the Investor. Neither such inquiries nor any other investigation conducted by or on behalf of the Investor or its representatives or counsel shall modify, amend, or affect the Investor’s right to rely on the truth, accuracy, and completeness of the disclosure materials and the Company’s representations and warranties contained herein.
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j.
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The execution, delivery, and performance of this Subscription Agreement by the Investor do not and will not, with or without the passage of time or the giving of notice, result in the breach of, or constitute a default, cause the acceleration of performance, or require any consent under, or result in the creation of any lien, charge or encumbrance upon any property or assets of the Investor pursuant to, any material instrument or agreement to which the Investor is a party or by which the Investor or its properties may be bound or affected, and, do not or will not violate or conflict with any provision of the articles of incorporation or bylaws, partnership agreement, operating agreement, trust agreement, or similar organizational or governing document of the Investor, as applicable.
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9. | Covenants. The Company covenants and agrees with the Placement Agent as follows: |
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a.
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The Company will promptly take or cause to be taken, from time to time, such actions as the Placement Agent may reasonably request to qualify the Units for offering and sale under the state securities, or blue sky, laws of such states or other jurisdictions as the Placement Agent may reasonably request and to maintain such qualifications in effect so long as the Placement Agent may request for the distribution of the Securities, provided, that in no event shall the Company be obligated to qualify as a foreign corporation in any jurisdiction in which it is not so qualified or to file a general consent to service of process in any jurisdiction or subject itself to taxation as doing business in any jurisdiction.
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b.
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The Company will apply the net proceeds from the sale of the Units in the manner set forth in the Offering Memorandum under the heading “Use of Proceeds.”
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c.
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Prior to 9:30 a.m. Philadelphia, Pennsylvania time on the business day immediately subsequent to the initial Closing Date, the Company shall issue a press release reasonably acceptable to the Placement Agent disclosing the closing of the transaction contemplated hereby.
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10.
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Requirement of Commission Filings.
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a.
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With a view to making available to the Investors the benefits of Rule 144 promulgated under the Securities Act (“Rule 144”), for a period of thirty-six (36) months following the final Closing Date, the Company agrees to:
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(i)
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make and keep public information available, as those terms are understood and defined in Rule 144;
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(ii)
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file with the Commission in a timely manner all reports and other documents required of the Company under the Securities Act and the Exchange Act; and
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(iii)
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furnish or make available to the Investors, promptly upon request, (i) a written statement by the Company, if true, that it has complied with the reporting requirements of the Exchange Act or confirm in writing that such Investor can sell Shares under Rule 144, (ii) a copy of the most recent annual or quarterly report of the Company and such other reports and documents so filed by the Company, and (iii) such other reports and documents of the Company as an Investor may reasonably request in availing itself of any rule or regulation of the Commission allowing an Investor to sell any such securities without registration (at any time after the Company has become subject to the reporting requirements of the Exchange Act), including without limitation any documents required by the Company’s transfer agent (including any applicable opinion of Company counsel) to allow for the transfer of shares and the removal of any legends from certificates representing Shares.
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b.
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At any time beginning on the date hereof and ending at such time that all of the Shares may first be sold without restriction or limitation pursuant to Rule 144, if the Company shall fail for any reason to satisfy the current public information requirement under Rule 144 (a “Public Information Failure”) then, as partial relief for the damages to the Investor by reason of any such delay in or reduction of its ability to sell the Shares (which remedy shall not be exclusive of any other remedies available at law or in equity), the Company shall, on the date on which such Public Information Failure occurs, and each 30th day thereafter, as applicable, issue to the Investor its ratable share (based on the number of Units purchased by the Investor in the Offering) at a rate of 3% of the shares purchased under the subscription agreements for each month that a Public Information Failure persists.
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11.
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Legend; Restrictions on Transfer.
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The Investor will not transfer any of the Shares unless such transfer is registered or exempt from registration under the Securities Act and applicable State Acts, and, if requested by the Company in the case of an exempt transaction, the Investor has furnished an opinion of counsel reasonably satisfactory to the Company that such transfer is so exempt. The Investor understands and agrees that (i) the Company shall have no obligation to honor transfers of any of the Shares in violation of such transfer restrictions, (ii) the Company shall be entitled to instruct any transfer agent or agents for the securities of the Company to refuse to honor such transfers and (iii) the certificate and other documents evidencing the Shares will bear the following legend:
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12.
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Indemnification of the Company and affiliates.
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Notwithstanding anything else contained herein to the contrary, the Investor hereby agrees to indemnify the Company, the Placement Agent and their respective employees, agents, affiliates, officers, directors, general partners, and the employees of each of them and to hold each of them harmless from and against any and all losses, claims, liabilities, damages, costs or expenses (including reasonable attorneys’ fees and expenses and costs of suit) incurred on account of, arising out of, or based upon:
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a.
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any inaccuracy or omission in the Investor’s declarations, representations and warranties as set forth herein or the failure of such Investor to comply with the covenants of the Investor contained herein; and
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b.
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the voluntary disposition of the Investor’s Shares in a manner contrary to the Investor’s declarations, representations and warranties as made herein.
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13.
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The Company agrees to indemnify and hold harmless Investor from and against any losses, claims, damages or liabilities to which Investor may become subject (under the Securities Act or otherwise) insofar as such losses, claims, damages or liabilities (or actions or proceedings in respect thereof) arise out of, or are based upon any breach of the representations or warranties of the Company contained herein or failure to comply with the covenants and agreements of the Company contained herein, and the Company will reimburse such Investor for any reasonable legal or other out-of-pocket expenses reasonably incurred in investigating, defending or preparing to defend any such action, proceeding or claim, or preparing to defend any such action, proceeding or claim, provided, however, that the Company shall not be liable in any such case to the extent that such loss, claim, damage or liability arises out of, or is based upon the breach of, or the inaccuracy or omission in, the Investor’s declarations, representations and warranties as made herein or the failure of Investor to comply with its covenants and agreements contained in this Subscription Agreement. The Company shall reimburse Investor for the indemnifiable amounts provided for herein on demand as such expenses are incurred.
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14.
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Notwithstanding any investigation made by any party to this Subscription Agreement, all covenants, agreements, representations and warranties made by the Company and the Investor herein will survive the execution of this Subscription Agreement, the delivery to the Investor of the Shares being purchased and the payment therefor.
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15.
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This Subscription Agreement may not be modified or amended except pursuant to an instrument in writing signed by the Company and the Investor.
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16.
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In case any provision contained in this Subscription Agreement should be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions contained herein will not in any way be affected or impaired thereby.
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17.
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This Subscription Agreement will be governed by, and construed in accordance with, the internal laws of the State of California, without giving effect to the principles of conflicts of law that would require the application of the laws of any other jurisdiction.
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18.
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All statements, requests, notices and agreements hereunder shall be in writing shall be delivered or sent by mail, telex or facsimile transmission, and shall be deemed sent when delivered personally or by facsimile transmission (with receipt acknowledged), one day after delivery to a recognized overnight courier service, or three days after deposit in the U.S. mail, certified mail, return receipt requested, as follows:
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a.
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if to the Placement Agent, to:
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Philadelphia Brokerage Corporation
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2 Radnor Corporate Center
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Suite 111
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Radnor, Pennsylvania 19087
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Attention: Robert Fisk
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Facsimile No.: (610) 975-0520
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b.
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if to the Company, to:
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Attention: Mark Selawski
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Facsimile: (949) 476-1122
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c.
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If to the Investor, to the address set forth on the signature page hereto.
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19.
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This Subscription Agreement may be executed in one or more counterparts (delivery of which may be by facsimile or as “pdf” or similar attachments to an electronic transmission), each of which will constitute an original, but all of which, when taken together, will constitute but one instrument, and will become effective when one or more counterparts have been signed by each party hereto and delivered to the other parties.
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20.
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The Investor acknowledges and agrees that such Investor’s receipt of the Company’s counterpart to this Subscription Agreement shall constitute written confirmation of the Company’s sale of Shares to such Investor.
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21.
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In the event that the Engagement Letter is terminated by the Placement Agent pursuant to the terms thereof, this Subscription Agreement shall terminate without any further action on the part of the parties hereto.
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1.
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Name:
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(Investor’s exact name, as it should appear in the records of the Company.)
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2.
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Describe any preexisting business or personal relationship between the undersigned and any director or officer of the Company (if any):
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(a)
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The undersigned’s individual net worth, or joint net worth with the undersigned’s spouse, exceeds $1,000,000, excluding the value of the primary residence. For purposes of this Questionnaire, an investor’s “net worth” is equal to the excess of total assets at fair market value over total liabilities. Net worth may include the equity value (i.e., current appraised value less mortgage indebtedness) of real property owned by the investor but must exclude the investor’s primary residence. Thus, if an investor calculated its net worth by including the net equity value of its primary residence, it must reduce its net worth for purposes hereof by such net equity value. Moreover, any indebtedness secured by the residence in excess of the value of the primary residence should be considered a liability and deducted from the investor’s net worth for purposes hereof, and any indebtedness secured by the primary residence up to the value thereof should be considered a liability and deducted from the investor’s net worth for purposes hereof if the amount of such indebtedness currently outstanding exceeds the amount outstanding 60 days prior to the date hereof, other than as a result of the acquisition of such primary residence.
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(b)
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The undersigned’s individual income (without the undersigned’s spouse) was in excess of $200,000 in each of the two most recent years or joint income with the undersigned’s spouse was in excess of $300,000 in each of those years, and the undersigned reasonably expects an income reaching the same income level in the current year. For purposes of this Questionnaire, individual income means adjusted gross income, as reported for federal income tax purposes, less any income attributable to a spouse or to property owned by a spouse, increased by the following amounts (but not including any amounts attributable to a spouse or to property owned by a spouse): (i) the amount of any tax exempt interest income received, (ii) the amount of losses claimed as a limited partner in a limited partnership, (iii) any deduction claimed for depletion, (iv) deductions for alimony paid, (v) amounts contributed to an IRA or Keogh retirement plan, and (vi) any amount by which income from long-term capital gains has been reduced in arriving at adjusted gross income pursuant to the provisions of Section 1202 of the Internal Revenue Code.
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4. Type of Organization (LLC, corporation, etc.):
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5. Date and place of organization:
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6. The undersigned is (Initial each of the following representations, AS APPLICABLE):
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(a)
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(___) a bank as defined in Section 3(a)(2) of the Securities Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act acting in either an individual or fiduciary capacity;
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(___) a broker or dealer registered pursuant to Section 15 of the Securities and Exchange Act of 1934, as amended;
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(I)
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(___) 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; |
(II)
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(___) an investment company registered under the Investment Company Act of 1940 or a business development company as defined in Section 2(a)(48) of that Act; or |
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(___) an insurance company as defined in Section 2(13) of the Securities Act; |
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(b)
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(___) a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940;
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(c)
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(___) a corporation, partnership, limited liability company, Massachusetts or similar business trust, or an organization described in Section 501(c)(3) of the Internal Revenue Code, not formed for the specific purpose of acquiring the securities offered with total assets in excess of $5,000,000;
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(d)
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(___) any trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in the rules and regulations of the Securities Act (a trust must attach a copy of its Declaration of Trust or other governing instrument, as amended, as well as all other documents that authorize the trust to invest in the securities);
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(e)
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(___) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 if the investment decision is made by a plan fiduciary, as defined in Section 3(21) of such Act, which is a bank, an insurance company, a savings and loan association, or a registered investment advisor;
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(___) an employee benefit plan with total assets in excess of $5,000,000; or
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(f)
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(___) an entity (including a revocable trust - a trust must attach a copy of its Declaration of Trust or other governing instrument, as amended, as well as all other documents that authorize the trust to invest in the securities) in which all of the equity owners are Accredited Investors as defined in Rule 501(a) of Regulation D. Note: each equity owner/trustee must submit an individual Questionnaire.
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(1)
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List all equity owners/trustees of the entity:
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(2)
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Type of entity:
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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 in determining whether the offering in which the undersigned proposes to participate is exempt from registration under the Securities Act and the rules promulgated thereunder;
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(ii)
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The undersigned will notify the Company immediately of any material change in any statement made herein occurring prior to the completion of the offering; and
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(iii)
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The undersigned has adequate means of providing for the undersigned’s current needs and personal contingencies, has no need for liquidity in its investment in the Common Stock, and is able to bear the economic risk of an investment in the Common Stock of the size contemplated. In making this statement, the undersigned at the present time could afford a complete loss of such investment.
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INDIVIDUALS: | ENTITIES: | |
Print Name
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Print Name of Subscriber
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Signature
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Authorized Signature
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Signature (if Joint Tenants
Or Tenants in Common)
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Print Name of Signatory and
Capacity in which Signed
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Warrant No.: ____ | ____________, 2012 |
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9.2
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Office; Transfer and Exchange of Warrant.
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ATHERONOVA INC.
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By:
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Name: | |||
Title: | |||
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________
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(a)
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Purchase ____________ shares of ________________ of AtheroNova Inc. pursuant to the terms of the attached Warrant and payment of the Warrant Price per share required under such Warrant accompanies this notice;
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________
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(b)
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Exercise the attached Warrant for [all of the shares] [______ of the shares] [cross out inapplicable phrase] purchasable under the Warrant pursuant to the cashless exercise provisions of Section 4.6 of such Warrant.
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