Subscription and Identification Form

Subscription and Identification Form

Private Placement - Reg-D - Accredited Investors Only
Are you ready to start?
Please read carefully.

The following form aims to collect all relevant information suitable for a Reg-D, and subsequent information to support the allotment of shares subject to all guidence and laws pretainent to this securities offering.

Please answer all questions to their fullest. Please note partial responses may be rejected. This offer is only suitable to accredited investors, you will be required to upload specific paperwork throughout the form to prove identity and right to purchase.

Please provide your email Address*

Confirmation Emailexample@example.com
Are you an Accredited Investor?*

YesNo

You answered No, You cannot complete this form

Are you applying as an individual or entity?*

IndividualEntity/Company

As an individual accredited investor, are you:*

A natural person with individual net worth (or joint net worth with spouse) in excess of $1 million, excluding primary residence value as specified.A natural person with individual income over $200,000, or joint income with spouse over $300,000, in each of the two most recent years and expecting the same this year.

Please enter your full name (as the Investor individual):*
Full name is as per a federal or state ID, first, middle and last name
Please enter your date of birth:*

MonthDayYear
Date
What is your net worth?*
Round to nearest $1,000
Please indicate whether you are investing the assets of any retirement plan, employee benefit plan or other similar agreement (such as an IRA or “Keogh” plan).*

YesNo

Because you answered “Yes,” please submit additional information with respect to such plan, including applicable documents granting you authority to invest assets of such retirement plan.*

Cancelof

Because you answered “No,” are you a person who has discretionary authority or control with respect to the Company’s assets or provides investment advice for a fee (direct or indirect) with respect to such assets, or a person directly or indirectly through one or more intermediaries, controlling any such person?*

YesNo
Because you answered “No,” are you a person who has discretionary authority or control with respect to the Company’s assets or provides investment advice for a fee (direct or indirect) with respect to such assets, or a person directly or indirectly through one or more intermediaries, controlling any such person?

YesNo

Is the Entity/Company

(a) a trust any portion of which is treated (under subpart E of part I of subchapter J of chapter 1 of subtitle A of the Code) as owned by a natural person (e.g., a grantor trust)

(b) an entity disregarded for federal income tax purposes and owned (or treated as owned) by a natural person or a trust described in clause (a) of this sentence (e.g., a limited liability company with a single Shareholder)

(c) an organization described in Sections 401(a) or 501 of the Code or (d) a trust permanently set aside or to be used for a charitable purpose?
YesNo
Is the Entity/Company acting on behalf of an unrelated third party (e.g., nominee arrangement)?*

YesNo

Because you indicated "Yes", please describe the arrangement

Does the Entity/Company have one or more ultimate beneficiaries who (a) are entitled to 10% or more of the proceeds from this investment or (b) hold 10% or more of the control rights of the Investor?*

YesNo

Because you indicated "Yes" please complete the below chart.

	Name of Investor and Each 10% Beneficial Owner	If the Investor or Any of the 10% Beneficial Owners Is Publicly Traded, Please Identify the Exchange for the Public Trading.	If the Investor or Any of the 10% Beneficial Owners Is a Regulated Entity, Please Identify Regulator and Jurisdiction.
1
2
3
4

Is the Entity/Company or any of the ultimate beneficiaries publicly traded?*

YesNo
If "yes" please cite exchange and ticker
Is the Entity/Company or any of the ultimate beneficiaries a regulated entity?*

YesNo
If "yes" please cite regulatory and jurisdiction

Please indicate whether or not more than Ten percent (10%) of the value of the ownership interest of any beneficial owner in the Investor is (or may at any time during the term of the Company be) attributable to the Investor’s (direct or indirect) interest in the Company;

YesNo
Please indicate whether or not it is a principal purpose of the Investor’s participation in the Company to permit any entity to satisfy the 100-partner limitation contained in U.S. Treasury Regulation Section 1.7704-l(h)(3).

YesNo
If you answered "yes" to either, please upload appropriate organizational documents, trust documents, or partnership or Bylaws stating, among other things, the powers of authority and signature(s).

Cancelof

Are shareholders, partners or other holders of equity or beneficial interests in the Investor able to decide individually whether to participate, or the extent of their participation, in the Investor’s investment in the Company (i.e., can shareholders, partners or other holders of equity or beneficial interests in the Investor determine whether their capital will form part of the capital invested by the Investor in the Company)?

YesNo
If you answered “Yes,” please upload relevant documents evidencing that the shareholders, partners or other holders of equity or beneficial interests in the Investor have agreed to for their capital to form part of the capital invested by the Investor in the Company.

Cancelof

Please indicate whether or not the Investor is, or is acting (directly or indirectly) on behalf of

(i) an employee benefit plan (within the meaning of Section 3(3) of ERISA), whether or not such plan is subject to Title I of ERISA

(ii) a plan, individual retirement account or other arrangement that is described in Section 4975 of the Code, whether or not such plan, account or arrangement is subject to Section 4975 of the Code

(iii) an insurance company using general account assets, if such general account assets are deemed to include the assets of any of the foregoing types of plans, accounts or arrangements for purposes of Title I of ERISA or Section 4975 of the Code under Section 401(c)(1)(A) of ERISA or the regulations promulgated thereunder

(iv) an entity whose assets are deemed to include the assets of any of the foregoing types of plans, accounts or arrangements (each of the foregoing described in clauses (i), (ii), (iii) and (iv) being referred to as a “Plan Investor”).
YesNo

Please indicate whether or not the Plan Investor is subject to Title I of ERISA or Section 4975 of the Code.

YesNo
If the answer is “Yes”, please indicate what percentage of the Plan Investor’s assets invested in the Company are the assets of “benefit plan investors” within the meaning of Section 3(42) of ERISA as modified by 29 CFR 2510.3-101(f): Percentage

If the Investor is investing the assets of an insurance company general account, please indicate what percentage of the insurance company general account’s assets invested in the Company are the assets of “benefit plan investors” within the meaning of Section 401(c)(1)(A) of ERISA or the regulations promulgated thereunder: Percentage
If the Plan Investor is not subject to Title I of ERISA or Section 4975 of the Code, please indicate whether or not such Plan Investor is subject to any other federal, state, local, non-U.S. or other laws or regulations that could cause the underlying assets of the Company to be treated as assets of the Plan Investor by virtue of its investment in the Company and thereby subject the Company and/or the Chief Executive Officer (or other persons responsible for the investment and operation of the Company’s assets) to laws or regulations that are similar to the fiduciary responsibility or prohibited transaction provisions contained in Title I of ERISA or Section 4975 of the Code.

YesNo

Because you answered “No,”

Please indicate whether the Investor is a person who has discretionary authority or control with respect to the Company’s assets or provides investment advice for a fee (direct or indirect) with respect to such assets,

or an affiliate of any such person. For this purpose, an “affiliate” of a person includes any person, directly or indirectly, through one or more intermediaries, controlling, controlled by, or under common control with, such person. “Control” with respect to a person other than an individual means the power to exercise a controlling influence over the management or policies of such person.
YesNo

Does the amount of the Investor’s subscription payment exceed 40% of the total assets (on a consolidated basis with its subsidiaries) of the Investor?

YesNo
If the Entity/Company is an entity substantially owned by ANY a “government entity” and the investment decisions of such entity are influenced, made or directed by such government entity, please provide the name of the government entity

Is the Investor a private investment company which is not registered under the 1940 Act in reliance on Section 3(c)(1) or (7) thereof?

YesNo
Was formation on or before April 30, 1996.

YesNo
Please indicate whether or not the Investor has obtained the consent of its direct and indirect beneficial owners to be treated as a “qualified purchaser” as provided in Section 2(a)(51)(C) of the 1940 Act and the rules and regulations thereunder.

YesNo
Please upload consent to be treated as a “qualified purchaser” as provided in Section 2(a)(51(C) of the 1940 Act and rules regulations thereunder

Cancelof

What is the U.S. Taxpayer Identification or Social Security Number:*
What is the Investor's/Entity/Company tax year end*

MonthDayYear
Date
If the Investor/Entity/Company is subject to the U.S. Freedom of Information Act, 5 U.S.C. § 552, (“FOIA”), any state public records access laws, any state or other jurisdiction’s laws similar in intent or effect to FOIA, or any other similar statutory or regulatory requirement that might result in the disclosure of confidential information relating to the Company, please indicate the relevant laws to which the Investor/Entity/Company is subject to and provide any additional explanatory information in the space below:

Primary Contact Person for This Account and for General Notices:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

For future distributions of cash, please wire funds to the following bank account:
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Routing Number
Bank Account Number
Transfer Reference
Bank SWIFT Code
If distributions are in-kind, and we are sendign to a brokerage, please name firm:
DTC Number for brokerage firm

ANTI-MONEY LAUNDERING INFORMATION FORM: The following is required in accordance with the AML provision of the USA PATRIOT ACT. Cite your investment objectives
Please cite your investment objectives*
This statement will be used with other information collected from the subscription form

Attestment

I attest, I am an accredited investor and the information supplied is true and correct
Please submit a copy of non-expired identification for the authorized signatory(ies) on the investment documents, showing name, date of birth, address and signature. The address shown on the identification document MUST match the Investor’s address shown on the Investor Signature Page.*

Cancelof

Attestment

I attest, I am an Entity/Company and the information supplied is true and correct
If the Investor is a corporation, limited liability company, trust or other type of entity, please submit the following requisite documents: (i) Articles of Formation, By-Laws, Certificate of Formation, Operating Agreement, Trust or other similar documents for the type of entity; and (ii) Corporate Resolution or power of attorney or other similar document granting authority to signatory(ies) and designating that they are permitted to make the proposed investment.*

Cancelof

Private Placement Subscription: Purchase Form
I wish to purchase Number of shares* at $4.00 per share. Please debit my PayPal/credit card, as per the "Calculation" field below, accordingly.
Calculation in $ due*
Important, Please read carefully.

Next you will sign and submit this form. A PDF version will be emailed to you. The PDF will have wire instructions to our legal escrow account, which you will need to complete before you share allotment can be reviewed. Following verification of your accredited investor status, review of your application and subscription, receipt of funds for purchasing the shares, an email will be sent to you regarding your allotment. should you have any questions please email: investors@medlab.group
Signature*

Powered by Jotform SignClear
Signature
Should be Empty:

Subscription and Identification Form

Are you ready to start?

You answered No, You cannot complete this form

For future distributions of cash, please wire funds to the following bank account:

ANTI-MONEY LAUNDERING INFORMATION FORM: The following is required in accordance with the AML provision of the USA PATRIOT ACT. Cite your investment objectives

Attestment

Attestment

Private Placement Subscription: Purchase Form

Important, Please read carefully.