EXHIBIT 10.4
APPENDIX D
Physicians Care for Connecticut, Inc.
SUBSCRIPTION AGREEMENT
(Individual Physician)
NAME & ADDRESS
Print (or type) below the name and address to
whom you would like your stock certificate sent
------------------------------------------------ Your Name
(Name)
------------------------------------------------ Your Street Address (No P.O. Boxes please, since
(Address) stock will be sent registered mail)
------------------------------------------------ Your City and State
(City) (State)
---------- Your Zip Code
(Zip)
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STOCK REGISTRATION
------------------------------------------------ Stock must be listed by individual name. Include
(Name) the first name, middle initial and last name of
Please Print or Type the shareholder. Avoid the use of two initials.
Please omit words that do not affect ownership
rights, such as "Mrs." "Mr." "Dr." "special
account," "single person," etc.
IF STOCK IS TO BE LISTED IN A CORPORATE OR
PRACTICE NAME, PLEASE USE SUBSCRIPTION AGREEMENT
(GROUP).
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PHONE & FAX NUMBERS
( ---) --------------------- Phone All telephone numbers will be kept confidential.
( ---) --------------------- Fax Telephone numbers will not be used for any
( ---) --------------------- Phone solicitation purposes.
( ---) --------------------- Fax
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MEDICAL ASSOCIATION MEMBERSHIP
/ / I am now a member of my state and/or county Subscribers must be members in County Medical
Medical societies. I hereby affirm that I Society (if a county medical association exists
previously have filed an application for in such county) and the State Medical
such membership. Association if available, or apply for such
membership.
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SHARES PURCHASED AND PRICE
A.Primary Care Physicians (See definition of Every physician must purchase one share of Class
Primary Care Physician ("PCP") contained on A Common Stock. No Physician may purchase more
page 48 of the Prospectus): than one share of Class A
Common Stock.
1 Class A Shares: (NOTE: PCPS MAY ONLY PURCHASE
1 SHARE OF CLASS A STOCK)
@ $3,000 per share if shares purchased ------------------------------------------------
before --------------------- $
--------------
@ $4,000 per share if shares purchased
after--------------------- $
--------------
Class B shares: (NOTE: PCPS MAY PURCHASE AS Specialist Physicians must purchase at least one
MANY CLASS B SHARES AS DESIRED BUT ARE NOT share of Class B Stock. There is no limit on the
REQUIRED TO PURCHASE ANY CLASS B SHARES) number of Class B shares which can be purchased
by any physician.
@ $3,000 per share if shares purchased
before --------------------- $
-------------- See definition of Specialist Physician contained
@ $4,000 per share if shares purchased on Page of the Prospectus.
after--------------------- $
--------------
Total: $ ------
B. Specialist Physician (See definition of The PROMPT SUBSCRIPTION DEADLINE is , For
Specialist Physician contained on page 48 of Subscription Documents Received on or before the
the Prospectus): Prompt Subscription Deadline, the Price is
1 Class A shares: (NOTE: SPECIALISTS MAY ONLY $3,000 per share (Class A or Class B). For
PURCHASE 1 SHARE OF CLASS A STOCK) Subscription documents received after the Prompt
@ $3,000 per share if shares purchased Subscription Deadline, the price is $4,000 per
before --------------------- $ share. Subscription documents are Received if
-------------- actually delivered to the Subscription Agent, or
@ $4,000 per share if shares purchased postmarked in each case on or before the Prompt
after--------------------- $ Subscription Deadline.
--------------
Total: $ ------
Class B shares: (NOTE: SPECIALISTS MUST
PURCHASE AT LEAST ONE SHARE OF CLASS B STOCK;
HOWEVER, AFTER PURCHASING A SHARE OF CLASS B
STOCK, SPECIALISTS MAY PURCHASE AS MANY CLASS B
SHARES AS DESIRED)
@ $3,000 per share if shares purchased
before --------------------- $
--------------
@ $4,000 per share if shares purchased
after--------------------- $
--------------
C. Hospital Investors.
Class B shares: (NOTE: HOSPITALS MAY NOT
PURCHASE CLASS A SHARES)
(NOTE: LICENSED HOSPITALS ARE REQUIRED TO
PURCHASE NOT LESS THAN 62.50 SHARES OF CLASS B
STOCK AT $4,000 DOLLARS PER SHARE, PROVIDED,
HOWEVER, THAT IF A VALIDLY LICENSED HOSPITAL
HAS LESS THAN 100 BEDS, THEN THE HOSPITAL IS
REQUIRED TO PURCHASE NOT LESS THAN 25 SHARES
OF CLASS B STOCK AT $4,000 PER SHARE.)
$ ------
Total: $ ------
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CHECK PAYABLE TO:
State Street Bank & Trust -- Escrow Agent 1) Attach a check for total Purchase Price made
payable to State Street Bank & Trust Escrow
Agent for
--------------------------
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SOCIAL SECURITY NUMBER
---- ---- ------- Social Security Number Print (or type) social security number.
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CERTIFICATION OF RESIDENCE
AND LICENSING
I so certify By signing opposite, you certify that you are a
resident of one of the following states (please
check one state):
-------------------------- / / Connecticut
(Sign Name) / / New York
/ / Rhode Island
/ / Massachusetts
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STOCK TRANSFER AND
REDEMPTION RESTRICTIONS
I so certify By signing opposite, you certify that you have
read and understand the restrictions on transfer
and redemption of the Common Stock set forth in
the Prospectus.
--------------------------
(Sign Name)
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REQUIRED DOCUMENTATION
Enclose the following document with signed
Subscription Agreement
/ / Check made payable to: State Street Bank &
Trust Co. -- Escrow Agent
/ / MedServ IPA Participation Agreement
/ / Physicians Care Primary Care Physician
Attachment or Physicians Care
Specialist Physician Attachment
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The undersigned agrees that after receipt by the Subscription Agent, this subscription agreement
may not be modified, withdrawn or canceled without the consent of Physicians Care for Connecticut,
Inc.
Under penalty of perjury, I certify that the Social Security Number and the information provided
in the subscription agreement are true, correct and complete, that I am not subject to back-up
withholding and that I am purchasing for my own account and that there is no agreement or
understanding regarding the transfer of this stock.
I acknowledge and agree that the purchase of the shares of stock in Physicians Care for
Connecticut, Inc. indicated above is subject to the terms, conditions, restriction, limitations
and obligations set forth in the prospectus.
Signature Date
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Newbury, Piret & Co., Inc.
Subscription Agent
0 Xxxxxx Xxxxx
00xx Xxxxx
Xxxxxx, XX 00000
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