IN WHICH TITLE IS TO BE HELD. (circle one)
IN WHICH TITLE IS TO BE HELD. ☐ Community Property* ☐ Individual Property ☐ Joint Tenancy With Right of s_ Separate Property Survivorship* ☐ Separate Property ☐ Corporate or Fund Owners ** ☐ Tenants-in-Common* ☐ Pension or Profit Sharing Plan ☐ Tenants-in-Entirety* ☐ Trust or Fiduciary Capacity (trust documents must accompany this form) ☐ Kxxxx Plan ☐ Fiduciary for a Minor ☐ Individual Retirement Account * Signature of all parties required ** In the case of a Fund, state names of all partners. ☐ Other (Please indicate) SUBSCRIPTION ACCEPTED: ZERIFY, INC. By: Mxxx X. Xxx DATE ZERIFY, INC. CONFIDENTIAL PURCHASER QUESTIONNAIRE Mxxx X. Xxx Zerify, Inc.
IN WHICH TITLE IS TO BE HELD. ¨ Individual o Joint Tenancy With Right of Survivorship* o Trust or Fiduciary Capacity (trust documents must accompany this form) o Tenants-in-Common* o Fiduciary or Custodian for a Minor o Individual Retirement Account o Entity ACCEPTANCE/NON-ACCEPTANCE BY FIRST COLEBROOK BANCORP, INC. ¨ The Company hereby accepts the foregoing subscription for ______________ shares of Company Common Stock at $20.00 per share. ¨ The Company does not accept the foregoing subscription in its entirety or for shares of Company Common Stock. FIRST COLEBROOK BANCORP, INC. By: Date: , 2016 Name: Its: SUBSCRIPTION PAYMENT INSTRUCTIONS No checks should be made payable to First Colebrook Bancorp, Inc. or funds wired directly to First Colebrook Bancorp, Inc. If you submit your subscription payment by check, your check must be made payable to “Bankers’ Bank Northeast, as Escrow Agent for First Colebrook Bancorp, Inc. Offering” and sent to the Company at the following address: First Colebrook Bancorp, Inc. 100 Xxxx Xxxxxx Xxxxxxxxx, Xxx Xxxxxxxxx 00000 Attention: Axxx X. Xxxxxxxx, Senior Vice President/Chief Financial Officer. Please note on the check that it is a “Subscription for Regulation A Common Stock Offering” If you wish to submit your subscription payment by wire transfer, please have your financial institution wire your funds using the following instructions: Sender ABA: ABA - Name - Address of the Sending Bank Receiver ABA: 000000000 – Bankers’ Bank Northeast Type Code: 1000 Business Function Code: CTR Beneficiary ID Code: D Beneficiary Identifier: 1380 (Note: Only the 4 account digits are to appear in this space) Beneficiary Name: & Address: BBN, as Escrow Agent for First Colebrook Bancorp, Inc. Offering 40 Xxxxxxx Xxxx. Xxxxxxxxxxx, XX 00000
IN WHICH TITLE IS TO BE HELD. (check one)
IN WHICH TITLE IS TO BE HELD. ☐ Community Property* ☐ Individual Property ☐ Joint Tenancy with Right of Survivorship* ☐ Separate Property ☐ Corporate or Fund Owners ** ☐ Tenants-in-Common* ☐ Pension or Profit-Sharing Plan ☐ Tenants-in-Entirety* ☐ Trust or Fiduciary Capacity (trust documents must accompany this form) ☐ Kxxxx Plan ☐ Fiduciary for a Minor ☐ Individual Retirement Account Other (Please indicate) * Signature of all parties required ** In the case of a Fund, state names of all partners. COMPANY SIGNATURE PAGE ACCEPTED AND AGREED TO: TERNIO, LLC: By: Name: Dxxxxx Xxxxxxxx Title: Date: CERTIFICATE OF ACCREDITED INVESTOR STATUS The undersigned is an individual “accredited investor,” as that term is defined in Regulation D under the Securities Act of 1933, as amended (the “Act”). The undersigned has checked the box below indicating the basis on which it is representing its status as an “accredited investor”: ☐ a bank as defined in Section 3(a)(2) of the Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Act whether acting in its individual or fiduciary capacity; a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934; an insurance company as defined in Section 2(a)(13) of the Act; 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; 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; a plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000; 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 either a bank, savings and loan association, insurance company, or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are “accredited investors”; ☐ a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940; ☐ an organization described in Section 501(c)(3) of the Internal Revenue Code, corpo...
IN WHICH TITLE IS TO BE HELD. ☐ Community Property* ☐ Individual Property ☐ Joint Tenancy With Right of s_ Separate Property Survivorship* ☐ Separate Property ☐ Corporate or Fund Owners ** ☐ Tenants-in-Common* ☐ Pension or Profit Sharing Plan ☐ Tenants-in-Entirety* ☐ Trust or Fiduciary Capacity (trust documents must accompany this form) ☐ Xxxxx Plan ☐ Fiduciary for a Minor ☐ Individual Retirement Account * Signature of all parties required ** In the case of a Fund, state names of all partners. ☐ Other (Please indicate) SUBSCRIPTION ACCEPTED: STRIKEFORCE TECHNOLOGIES, INC. By: Xxxx X. Xxx, CEO DATE STRIKEFORCE TECHNOLOGIES, INC. CONFIDENTIAL PURCHASER QUESTIONNAIRE Xxxx X. Xxx, CEO StrikeForce Technologies, Inc.
IN WHICH TITLE IS TO BE HELD. ☐ Community Property* ☐ Individual Property ☐ Joint Tenancy With Right of s_ Separate Property Survivorship* ☐ Separate Property ☐ Corporate or Fund Owners ** ☐ Tenants-in-Common* ☐ Pension or Profit Sharing Plan ☐ Tenants-in-Entirety* ☐ Trust or Fiduciary Capacity (trust documents must accompany this form) ☐ Xxxxx Plan ☐ Fiduciary for a Minor ☐ Individual Retirement Account * Signature of all parties required ** In the case of a Fund, state names of all partners. ☐ Other (Please indicate) SUBSCRIPTION ACCEPTED: STRIKEFORCE TECHNOLOGIES, INC. By: Xxxx X. Xxx DATE STRIKEFORCE TECHNOLOGIES, INC. CONFIDENTIAL PURCHASER QUESTIONNAIRE Xxxx X. Xxx StrikeForce Technologies, Inc. Re: STRIKEFORCE TECHNOLOGIES, INC. The following information is furnished to you in order for you to determine whether the undersigned is qualified to purchase shares of Common Stock (the “Shares”) in the above referenced Company pursuant to Section 3(b) of the Securities Act of 1933, as amended (the “Act”), Regulation A promulgated thereunder, and appropriate provisions of applicable state securities laws. I understand that you will rely upon the following information for purposes of such determination, and that the Shares will not be registered under the Act in reliance upon the exemption from registration provided by Section 3(b) of the Act, Regulation A, and appropriate provisions of applicable state securities laws. ALL INFORMATION CONTAINED IN THIS QUESTIONNAIRE WILL BE TREATED CONFIDENTIALLY. However, I agree that you may present this questionnaire to such parties as you deem appropriate if called upon to establish that the proposed offer and sale of the Shares is exempt from registration under the Act or meets the requirements of applicable state securities laws.
IN WHICH TITLE IS TO BE HELD. Community Property* /_/ Individual Property /_/ Joint Tenancy With Right of Survivorship* /_/ Separate Property /_/ Corporate or Fund Owners** /_/ Tenants-in-Common* /_/ Pension or Profit Sharing Plan /_/ Tenants-in-Entirety* /_/ Trust or Fiduciary Capacity (trust documents must accompany this form) /_/ Kxxxx Plan /_/ Fiduciary for a Minor /_/ Individual Retirement Account /_/ Other (Please indicate) * Signature of all parties required ** In the case of a Fund, state names of all partners. SUBSCRIPTION ACCEPTED:
IN WHICH TITLE IS TO BE HELD. Individual Property __ Community Property * __ Pension or Profit Sharing Plan __ Joint Tenancy with __ Separate Property __ Corporate or Partnership** Right of Survivorship* __ Tenants-in-Entirety* __ Fiduciary for a Minor __ Individual Retirement Acct. __ Tenants-in-Common* __ Trust or Fiduciary Capacity __ Other (Please indicate) __ Kxxxx Plan (Trust documents must accompany this form) *Signature of all parties required. **In the case of partnership, state names of all partners. ________________________________________________________________________________________________________ SUBSCRIPTION ACCEPTED: SKYLYFT Media Network, Inc. By:______________________________________________ DATE: ________________________ ,2006
IN WHICH TITLE IS TO BE HELD. Community Property* Individual Property Joint Tenancy with Right of Survivorship* Separate Property Corporate or Fund Owners ** Tenants-in-Common* Pension or Profit Sharing Plan Tenants-in-Entirety* Trust or Fiduciary Capacity (trust documents must accompany this form) Xxxxx Plan Fiduciary for a Minor Individual Retirement Account * Signature of all parties required ** In the case of a Fund, state names of all partners. Other (Please indicate): SUBSCRIPTION ACCEPTED: Easy Choice Business Solutions, Inc.
