SUBSCRIBER ADDRESS INFORMATION Sample Clauses

SUBSCRIBER ADDRESS INFORMATION. For individual subscribers this address should be the Subscriber’s primary legal residence. For entities other than individual subscribers, please provide address information for the entities primary place of business. Information regarding a joint subscriber should be included in the column at right. Legal Address Legal Address City, State and Zip Code City, State and Zip Code Tax ID (EIN, SSN, or ITIN) Tax ID (EIN, SSN, or ITIN) / / Telephone Number/Facsimile Number Telephone Number/Facsimile Number Email Address Email Address ALTERNATE ADDRESS INFORMATION: Please enter an alternate address if you wish to receive correspondence at an address other than the address listed above. Alternative Address for Correspondence Alternative Address for Correspondence City, State and Zip Code City, State and Zip Code Other (telephone, fax, email) Other (telephone, fax, email) AGREED AND SUBSCRIBED AGREED AND SUBSCRIBED This ____ day of ____________, 2015 This ____ day of ____________, 2015 Subscriber: SAFETY QUICK LIGHTING & FANS CORP. By: By: Xxxx X. Xxxxx Name: Chief Executive Officer Title: CERTIFICATE OF SIGNATORY (To be completed if the Securities are being subscribed for by an entity) I, ____________________________________________________ , am the_______________________________ of _____________________________________________ (the “Entity”). I certify that I am empowered and duly authorized by the Entity to execute and carry out the terms of the Securities Subscription Agreement and to purchase and hold the Securities, and certify further that the Securities Subscription Agreement has been duly and validly executed on behalf of the Entity and constitutes a legal and binding obligation of the Entity.

SUBSCRIBER ADDRESS INFORMATION. For individual subscribers this address should be the Subscriber’s primary legal residence. For entities other than individual subscribers, please provide address information for the entities primary place of business. Legal Address Copy To City, State and Zip Code Legal Address Tax ID (EIN, SSN, OR ITIN) City, State and Zip Code Telephone Number / Facsimile Number Telephone Number / Facsimile Number Email Address Email Address ALTERNATE ADDRESS INFORMATION: Please enter an alternate address if you wish to receive correspondence at an address other than the address listed above. Alternative Address for Correspondence Alternative Address for Correspondence City, State and Zip Code City, State and Zip Code Other (telephone, fax, email) Other (telephone, fax, email) AGREED AND SUBSCRIBED AGREED AND SUBSCRIBED Date: Date: Subscriber: SAFETY QUICK LIGHTING & FANS CORP. By: By: Name: Xxxx X. Xxxxx Title: Chief Executive Officer CERTIFICATE OF SIGNATORY (To be completed if the Securities are being subscribed for by an entity) I, , am the_______________________________ of _______________ (the “Entity”). I certify that I am empowered and duly authorized by the Entity to execute and carry out the terms of the Securities Subscription Agreement and to purchase and hold the Securities, and certify further that the Securities Subscription Agreement has been duly and validly executed on behalf of the Entity and constitutes a legal and binding obligation of the Entity.