Individual Subscriber. If the Subscriber is an individual, ---------------------- then the Subscriber (check an applicable box): [ ] is a director, executive officer or general partner of the issuer of the Common Stock being offered or sold or a director, executive officer or general partner of a general partner of that issuer. [ ] has an individual net worth, or joint net worth with that person's spouse, at the time of his purchase exceeding $1,000,000. [ ] had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year. [ ] none of the above. _____________ (Initial)
Individual Subscriber. If the Subscriber is an individual, the Subscriber is at least 18 years of age and a bona fide resident and domiciliary (not a temporary or transient resident) of the state or country indicated on the signature page hereof and the Subscriber has no present intention of becoming a resident of any other state or jurisdiction;
Individual Subscriber. If the Subscriber is an individual, then the Subscriber (check an applicable box):
Individual Subscriber. In the case of a Subscriber who is a natural person, in addition to the above, please fill in the following details: Nationality∗ : Date of Birth : Place of Birth : I.D. / Passport Number∗ : Occupation : Country of Tax Residency : Taxpayer Identification Number : Country of Origin of Source of Funds : Please confirm how the funds which will be used for investment have been accumulated (check all relevant boxes): Employment / Self Employment Income Inheritance or Gift Investment Income Matured Investment Lump Sum on Retirement Court Award / Litigation Settlement Redundancy Payment Divorce Settlement Sale of Property Others – please specify below: ∗ In the case where a Subscriber has dual nationality, please provide the relevant information in respect of each nationality.
Individual Subscriber. As described below, individual Subscribers can evidence Accredited Investor status based on any one of the following: Income, Net Worth or Third Party Verification:
Individual Subscriber. If the Subscriber receive the Securities is an individual, the Subscriber is at least 18 years of age and a bona fide resident and domiciliary (not a temporary or transient resident) of the state or country indicated on the signature page hereof and the Subscriber has no present intention of becoming a resident of any other state or jurisdiction;
Individual Subscriber. Dated: January 13, 2000. ------------------------------------ ------------------------------------ ------------------------------------ ------------------------------------ Signature Signature ------------------------------------ ------------------------------------ Name Typed or Printed Name Typed or Printed ------------------------------------ ------------------------------------ Residence Address Residence Address ------------------------------------ ------------------------------------ ------------------------------------ ------------------------------------ ------------------------------------ ------------------------------------ City, State and Zip Code City, State and Zip Code ------------------------------------ ------------------------------------ Mailing Address Mailing Address ------------------------------------ ------------------------------------ ------------------------------------ ------------------------------------ City, State and Zip Code City, State and Zip Code ------------------------------------ ------------------------------------ Tax Identification or Social Tax Identification or Social Security Number Security Number
Individual Subscriber s/ Xxxxxxx X.Xxxxxxx ------------------------------------------------------------- Signature of Xxxxxxx X. Xxxxxxx The Subscription and Investment Representation Agreement is accepted effective as of April 15, 2004. Photo Control Corporation By: /s/ Xxxxxx Xxxxxxx -------------------------------- Its: President
Individual Subscriber. If the Subscriber is an individual, then the Subscriber (check an applicable box): [ ] is a director, executive officer or general partner of the issuer of the Common Stock being offered or sold or a director, executive officer or general partner of a general partner of that issuer. [ ] has an individual net worth, or joint net worth with that person's spouse, at the time of his purchase exceeding $1,000,000. [ ] had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of SLW Enterprises Inc. -- Subscription Agreement $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year. [ ] none of the above. --------
