Amount of Subscription. The undersigned hereby subscribes to _____________ Shares for an aggregate amount of $___________. “PURCHASER” Check enclosed in the amount of $____________ or Wire Transfer Sent in the Amount of $__________ Subscribed for: _______________ Shares. Social Security or Taxpayer I.D. Number [required if applicable]: ____________________________ Business Address (including zip code): ____________________________ Business Phone: ( ) ____________________________ Residence Address (including zip code) ____________________________ Residence Phone: ( ) ____________________________ All communications to be sent to: Business or Residence Address Name Shares should be registered in:_________________________________________________ If different than subscriber name please advise of the reason for such difference: __________________________________________________________________ Address for registration of shares:___________________________________________________ Email Address:__________________________________________________________________ Please indicate on the following pages the form in which you will hold title to your interest in the securities. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SECURITIES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, THE SECURITIES AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the securities, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor’s domicile and his or her particular personal circumstances. Please select one of the following forms of ownership: ___ INDIVIDUAL OWNERSHIP (one signature required) ___ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) ___ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) ___ TENANTS IN COMMON (both or all parties must sign) ___ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign, and include a copy of the Partnership Agreement) ___ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized t...
Amount of Subscription. Number of Shares: ___________________
Amount of Subscription. The undersigned hereby subscribes to purchase an aggregate of ___________ Units for a total of $______________.
Amount of Subscription a. Shares of Stock (including fractions thereof) $1.00 minimum investment, 1 share.
Amount of Subscription. (a) Number of Units (including fractions thereof) of the Company): __________
Amount of Subscription a. Number of Units of the Company ________________
Amount of Subscription. Number of Units: 18% Convertible Promissory Note in the principal amount of $200,000 5 year Warrants to purchase 54,000 shares for $2.70 per share (check one) ____ Corporation under the laws of ____ Partnership the State of __________ ____ Limited Partnership under the laws ____ Trust of _____________ Ö Other (Specify): ____ Limited Liability Company Individual 0000 XX 000xx Xxxxxx, #0000 Address (Name of entity) Xxxxx, XX 00000 By: /s/ Xxxxxx Xxxxxxx City Zip Withheld Xxxxxx Xxxxxxx Taxpayer Identification No. Name Representative Capacity ………………………………………………………………………………………………………………………… Subscription Accepted: QUAMTEL, INC. By: /s/ Xxxxxx Xxxxxxx Xxxxxx Xxxxxxx, CEO-President
Amount of Subscription. The undersigned hereby subscribes to purchase 185,185 Shares in connection with this Subscription for a total of $250,000. This Agreement is executed (on the applicable following page) this 17th day of July, 2013. Subscription Agreement Xxxxx Energy, Inc.
Amount of Subscription. Twenty Five Thousand Five Hundred Dollars in common stock of Solanbridge Group, Inc. EVENTUS CAPITAL INC. $25,500 By: /s/ Dxxxx Xxxxx Amount of Subscription Signature 850,000 Dxxxx Xxxxx Number of Shares Purchased Name (Please Print) _________________________________ Street Address _________________________________ City State Zip Code _________________________________ Telephone Number
Amount of Subscription. (a) Amount of Investment: _________________
