EXHIBIT 10.16
SUBSCRIPTION AGREEMENT
WIEN GROUP, INC.
c/o Xxxx X. Xxxxxx
000 Xxxxxxxxxx Xxxx
Xxxxxx Xxxx, Xxx Xxxxxx 00000
The Investor named below, by payment of the purchase price for such
Common Shares, by the delivery of a check payable to Wien Group, Inc., hereby
subscribes for the purchase of the number of Common Shares indicated below of
Wien Group, at a purchase price of $0.20 per Share as set forth in the
Prospectus.
By such payment, the named Investor further acknowledges receipt of the
Prospectus and the Subscription Agreement, the terms of which govern the
investment in the Common Shares being subscribed for hereby.
A. INVESTMENT: (1) Number of Shares: _______________________________
(2) Total Contribution ($0.20 @ Share): $____________
Date of Investor's check: _______________ __, 200_
B. REGISTRATION:
(3) Registered owner: ______________________________
Co-Owner: ___________________________________________
(4) Mailing address: ______________________________
City, State & zip: __________________________________
(5) Residence Address (if different from above):
City, State & zip: __________________________________
(6) Birth Date: ______/______/______
(7) Employee or Affiliate: Yes ______ No ______
(8) Social Security No.: ______/______/______
U.S. Citizen [ ] Other [ ]
Co-Owner Social Security No.: ______/______/______
U.S. Citizen [ ] Other [ ]
Corporate or Custodial:
Taxpayer ID #: ______/______/______
U.S. Citizen [ ] Other [ ]
(9) Telephone (H) ( ) ______________________
FORM OF OWNERSHIP:
[ ] Individual Ownership [ ] Joint Tenants with Right of Survivorship
[ ] Community Property [ ] Tenants in Common
[ ] Tenants by the Entirety [ ] Corporate Ownership
[ ] Partnership Ownership [ ] Custodian for a Minor
[ ] Trust (see below) [ ] XXX or Pension Plan
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Date Trust Established: _________________________________________________
Name of Trustee or other Administrator __________________________________
IN WITNESS WHEREOF, the undersigned has executed this Subscription
Agreement as of this ____ day of ___________, 2003.
Individuals:
-------------------------------------------------
Registered Owner
Signature of Joint Tenant or Tenant in Common
-------------------------------------------------
Registered Co-Owner
For Trusts, Corporations, Partnerships
-------------------------------------------------
Authorized Signatory
By: _______________________________________________
Print capacity (Trustee, President, General Partner or Manager) of
authorized signatory
MAIL COMPLETED AGREEMENT AND CHECK TO:
WIEN GROUP, INC.
c/o Xxxx X. Xxxxxx
000 Xxxxxxxxxx Xxxx
Xxxxxx Xxxx, Xxx Xxxxxx 00000
Agreed to and accepted by WIEN GROUP, INC., a Delaware corporation
By:_____________________________________, its ____________________________
=====================================================================
FOR WIEN GROUP USE ONLY:
Date Received: ________________________________________________
Date Accepted/Rejected ________________________________________
Subscriber's Check Amount: _______________________
Check No. ___________________ Date Check ________________
Deposited ________________________________
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