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EXHIBIT 99
FLORIDA COASTLINE COMMUNITY GROUP, INC.
SUBSCRIPTION AGREEMENT
TO: Xxxx X. Xxxxxxx, Chief Executive Officer
Florida Coastline Community Group, Inc.
0000 Xxxxx Xxxxxxx Xxxxx
Xxxxx, Xxxxxxx 00000
Ladies and Gentlemen:
You have informed me that Florida Coastline Community Group, Inc. (the
"Company") is offering up to 1,000,000 shares of common stock at $.01 par value
per share (the "Common Stock") at a price of $10.00 per share as described in
and offered pursuant to the Prospectus furnished to the undersigned herewith
(the "Prospectus"). In addition, you have informed me that the minimum
subscription is 250 shares and the maximum subscription of 50,000 shares.
1. SUBSCRIPTION. Subject to the terms and conditions hereof, the
undersigned hereby tenders this subscription, together with payment in
the United States currency by check bank draft or money order payable
to "The Banker's Bank of Florida", Escrow Agent for Florida Coastline
Community Group, Inc., or any other consideration satisfactory to the
Company (the "Funds"), representing the payment of $10.00 per share
for the number of shares of the Common Stock indicated below.
2. ACCEPTANCE OF SUBSCRIPTION. It is understood and agreed that the
Company shall have the right to accept or reject this subscription in
whole or in part, for any reason whatsoever. The Company shall reject
this subscription, if at all, in writing within ten business days
after receipt of this subscription. The Company may reduce the number
of shares for which the undersigned has subscribed, indicating
acceptance of less than all of the shares subscribed on its written
form of acceptance.
3. ACKNOWLEDGMENTS. The undersigned hereby acknowledged receipt of a copy
of the Prospectus and agrees to be bound by the terms of this
Agreement and the Escrow Agreement.
4. REVOCATION. The undersigned agrees that once this Subscription
Agreement is accepted by the Company, it may not be withdrawn.
Therefore, until the earlier of the expiration of five business days
after receipt by the Company of this Subscription Agreement or
acceptance of this Subscription Agreement by the Company, the
undersigned may withdraw this subscription and receive a full refund
of the subscription price. The undersigned agrees that, except as
provided in this Section 4, he or she shall not cancel, terminate or
revoke this Subscription Agreement or any agreement of the undersigned
made hereunder and that this subscription Agreement shall survive the
death or disability of the undersigned.
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FLORIDA COASTLINE COMMUNITY GROUP, INC.
SUBSCRIPTION AGREEMENT
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BY EXECUTING THIS SUBSCRIPTION AGREEMENT, THE SUBSCRIBER IS NOT WAIVING ANY
RIGHTS HE OR SHE MAY HAVE UNDER FEDERAL SECURITIES LAWS, INCLUDING THE
SECURITIES ACT OF 1933 AND THE SECURITIES EXCHANGE ACT OF 1934.
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Please fill in the information requested below, make your CHECK PAYABLE TO:
"THE BANKERS BANK, ESCROW AGENT FOR FLORIDA COASTLINE COMMUNITY GROUP, INC.",
and mail a) Subscription Agreement; b) Stock Certificate Registration
Instructions; and c) check to the attention of:
Xxxx X. Xxxxxxx
Florida Coastline Community Group, Inc.
0000 Xxxxx Xxxxxxx Xxxxx
Xxxxx, Xxxxxxx 00000
Number of Shares Subscribed:
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Funds Tendered @ $10.00 per
share subscribed:
$--------------------
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Signature of Subscriber
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Name (Print or Type)
Date:
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PHONE NUMBER: HOME: ( ) OFFICE: ( )
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RESIDENCE ADDRESS:
CITY: STATE: ZIP:
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SOCIAL SECURITY
NUMBER OR OTHER
TAXPAYER
IDENTIFICATION
NUMBER:
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FLORIDA COASTLINE COMMUNITY GROUP, INC.
SUBSCRIPTION AGREEMENT
If shareholder(s) of record is (are) other than individual subscriber:
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Signature of Authorized Person
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Name (Print or Type)
Date:
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Please indicate how held:
___ Corporation Name:_____________________________
___ Limited Liability Company Name:_____________________________
___ Partnership Name:_____________________________
___ Trust Name:_____________________________
___ Joint Tenants* Name:_____________________________
___ Other (Identify ____________) Name:_____________________________
* Joint Tenants will be assumed to be Joint Tenants With Right of Survivorship
unless otherwise noted.
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PHONE NUMBER: HOME: ( ) OFFICE: ( )
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RESIDENCE ADDRESS:
CITY: STATE: ZIP:
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SOCIAL SECURITY
NUMBER OR OTHER
TAXPAYER
IDENTIFICATION
NUMBER:
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PHONE NUMBER: HOME: ( ) OFFICE: ( )
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RESIDENCE ADDRESS:
CITY: STATE: ZIP:
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SOCIAL SECURITY
NUMBER OR OTHER
TAXPAYER
IDENTIFICATION
NUMBER:
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