Memory Lane Syndication, Inc. Subscription Agreement for Common Stock
EXHIBIT 99.1
Memory Lane Syndication, Inc.
Subscription Agreement for Common Stock
Memory Lane Syndication, Inc.
0000 Xxxx Xxxxxx Xxxx
Xxxxx 000
Xxxxxxx, XX 00000
Ladies and Gentlemen:
I desire to purchase _____________________shares of Memory Lane Syndication, Inc. (the “Company”) at $0.01 per share for a total investment of $------------------- pursuant to the terms of the prospectus dated [ ], 2009. Accompanying this subscription is the undersigned’s check in the full amount of the subscription payable to “Memory Lane Syndication, Inc.” The undersigned represents to the Company that it has received and read the Company’s prospectus dated [ ], 2009 and that the undersigned has the authority to enter into this subscription agreement on behalf of the person(s) or entity registered above.
The Shares are to be issued in |
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(check one box): |
Print Name of Investor |
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o____ individual name |
___________________________________ |
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Print Name of Joint Investor (if applicable) |
o____ joint tenants with rights of survivorship |
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___________________________________ |
o____ tenants in entirety |
Signature of Investor |
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o____ corporation (an officer must sign) |
___________________________________ |
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Signature of Joint Investor |
o____ partnership (all general partners must sign) |
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___________________________________ |
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Print Name of Corporation, Partnership or |
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other Institutional Investor |
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By:________________________________ |
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Title:_______________________________ |
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Investor’s complete address: |
___________________________________ |
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(Street) |
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___________________________________ |
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(City) (State) (Zip) (Country) |
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Please check one of the following |
o U.S. Citizen |
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o U.S. Citizen residing outside the U.S. |
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o Resident Alien |
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o Non-U.S. Citizen |
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o Entity formed in the U.S. (specify domicile: ____) |
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o Non-U.S. Entity |
Social Security Number (if individual investor) |
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Taxpayer Identification Number (if applicable) |
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Accepted as of this ______ day of __________________ 0000
Xxxxxx Xxxx Syndication, Inc. |
By: __________________________________ Xxxxxx Xxxxx, President and Sole Director |