1. this subscription form is for use by united states accredited investors. 2. complete the information on page 2 of this subscription agreement. 3. complete : ( a ) a us investor questionnaire ( the “ us accredited investor questionnaire ” ) attached as exhibit a to this subscription agreement ; and ( b ) a canadian investor questionnaire ( the “ canadian investor questionnaire ”, and together with the us accredited investor questionnaire, the “ questionnaires ” ) attached as exhibit b hereto. 4. all other information must be filled in where appropriate. 8, 000 units us $ 1. 25 per unit for a total purchase price of us $ 10, 000 the subscriber or the beneficial purchaser owns, directly or indirectly, the following securities of the issuer : [ check if applicable ] the subscriber or the beneficial purchaser is [ ] an insider of the issuer or [ ] a registrant. 8, 000 units us $ 1. 25 per unit for a total purchase price of us $ 10, 000 the subscriber or the beneficial purchaser owns, directly or indirectly, the following securities of the issuer : [ check if applicable ] the subscriber or the beneficial purchaser is [ ] an insider of the issuer or [ ] a registrant. registration instructions delivery instructions name to appear on certificate name and account reference, if applicable account reference if applicable contact name address address telephone number registration instructions delivery instructions name to appear on certificate name and account reference, if applicable account reference if applicable contact name address address telephone number execution by subscriber : details of beneficial purchaser x ( if not the same as subscriber ) signature of individual ( if subscriber is an individual ) x authorized signatory ( if subscriber is not an individual ) name of beneficial purchaser ( please print ) name of subscriber ( please print ) e - mail address of beneficial purchaser name of authorized signatory ( please print ) telephone number of beneficial purchaser address of subscriber address of beneficial purchaser ( residence ) telephone number of subscriber accepted this day of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, 2012 anavex life sciences corp. e - mail address of subscriber per : social security / tax i. d. no. of subscriber authorized signatory execution by subscriber : details of beneficial purchaser x ( if not the same as sub