Subscription Agreement
Exhibit
10.19
To
U.S. Dry Cleaning Corporation:
I/we
hereby subscribe for units of securities, each unit consisting of one share
of
common stock and one redeemable warrant to purchase one share of common stock,
of U.S.
Dry
Cleaning Corporation (the
“Company”), in the amounts and name(s) shown below. The signature(s) affixed
below acknowledge(s) that I/we have received the Prospectus dated
[________________].
I/we
further acknowledge that my current residence is in the state of
__________________.
Please
Complete If You Are Using A Broker Dealer: The
broker dealer through whom I am making this purchase is _____________________
(“Broker”).
This
subscription represents my authorization to apply for payment of this
subscription, the cash equivalent balance present on account in my/our name(s)
at the Broker.
I/we
understand that the Company will be relying on the above representations by
me/us.
Please
apply $___________ as
payment for ____________ units
at
$2.50;
total
$______________ and
register the units in the following name(s) and amount(s):
(Please
Print Name of Individual(s) or Trust Name)
Name(s):_____________________________________________________________________________________________________________
Number
of
unit(s):____________________________
As:
(check
one) □Individual
□Joint
Tenancy □Husband
& Wife as community property
□Tenants
in Common □Corporation
□Trust
□
XXX □Other:
_________________________
For
The Person(s) Who Will Be Registered Holder Of The Units:
Mailing
Address (P.O. Box not Acceptable):
_________________________________________________________________________________
City:
_____________________________ State/Province:_______________
Zip/Post
Code: __________________________________________
Home
Phone:_____________________________ Work
Phone:_________________________________________________________________
Social
Security or Taxpayer ID Number(s):
__________________________________________________________________________________
Please
Complete If You Are Using An XXX Account:
Name
of
Firm: ________________________________________ Account
Name: ___________________________________________________
Account
Number: __________________ Address:__________________
State_____________
Zip
Code:
______________________________
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No
Subscription is effective until accepted by the Company and the Underwriter.
The
undersigned understands that this subscription may be accepted or rejected
in
whole or in part by the Company or the Underwriter in its sole discretion and
that this subscription is and shall be irrevocable unless the Company or
Underwriter for any reason rejects this subscription.
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Subscriber Signature |
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Subscriber
Signature
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Date
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Subscription
Accepted by U.S. Dry Cleaning Corporation:
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Xxxxxx X. Xxx, Chief Executive Officer |
Date
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Acknowledged
by Underwriter:
US
EURO Securities, Inc.
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Xxxxxxx Xxx Xxxxxx, Chairman |
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