CHINA NORTHERN MEDICAL DEVICE, INC. – COMMON STOCK SUBSCRIPTION AGREEMENT
Exhibit 99.1
CHINA NORTHERN MEDICAL DEVICE, INC. – COMMON STOCK
Investment
I desire to purchase _____________________ shares of China Northern Medical Device, Inc. at $0.20 per share for a total of $___________________
Make Checks Payable to:
China Northern Medical Device, Inc.
Subscriber Information: Please clearly print name(s) in which Shares are to be acquired. All correspondence will go to the Investor Residence Address
Investor 1 (First, Middle I., Last):
______________________________________________________________________________________________________
Investor 2 (First, Middle I. Last):
______________________________________________________________________________________________________
Registration for the Investment (how the investment should be titled):
________________________________________________________________________________________
Investor Residence Address 1:
Check one of the following:
______________________________________________________________________________________________
£
U.S. Citizen
Investor Residence Address 2:
£
Resident Alien
____________________________________________________________________
City,
State
ZIP Code
£
Foreign Resident; Country ________
________________________________________, ________, _______________
£
U.S. Citizen residing outside the U.S.
Enter the taxpayer identification number. For most individual taxpayers, it is their Social Security Number. Note: If the purchase is in more than one name, the number should be that of the first person listed. For IRAs, Keoghs, and qualified plans, enter both the Social Security Number and the Taxpayer Identification Number for the plan.
Social Security Number
Taxpayer Identification Number (if applicable)
________-_____-_________
_____-________________________________
Form of Ownership (Individual, XXX, Trust, UGMA, Pension Plan, etc.)
_______________________________________________________________________________
Subscriber Signature: The undersigned has the authority to enter into this subscription agreement on behalf of the person(s) or entity registered above.
Authorized Signature of Investor 1
________________________________________
Date:_____________________________________
Authorized Signature of Investor 2
________________________________________
Date:_____________________________________
_______________________________________________________________________________________________________________________________
Company’s Acceptance (To be completed only by an authorized representative of the Company.)
The foregoing subscription is accepted this ____________ day of ________________, _____
___________________________________
Authorized Representative of the Company
