PGI ENERGY FUND I SERIES 2010, INC. SUBSCRIPTION AGREEMENT
Exhibit 99(a)
PGI ENERGY FUND I SERIES 2010, INC.
The undersigned subscriber (the “Subscriber”) and co-subscriber, if any (the “Co-Subscriber”), desire(s) to subscribe for and purchase shares of common stock, $.01 par value per share (“Common Stock”), of PGI ENERGY FUND I SERIES 2010, Inc., a Texas corporation (the “Company”), to be issued by the Company upon the terms set forth in this Subscription Agreement and pursuant to the Company’s prospectus, filed in Registration Statement Form S-1 File No. 333-168524 filed on August 04, 2010, and all amendments and supplements thereto, if any (the “Prospectus”), related to the offer, sale and issuance (the “Offering”) of up to a maximum of 85,000,000 shares of the Company’s Common Stock (the “Shares”) by the Company in a self-underwritten, “best efforts” offering of the Shares pursuant to the Prospectus.
If you need assistance in completing this Subscription Agreement, please contact Xxxxxxxxxx Xxxxxx, Chief Executive Officer, of the Company at 0000 Xxxxxxxxx Xxxx, Xxxxx 0000, Xxxxxxx, XX. 77074 or by telephone at (000) 000-0000 (000) 000-0000, and he will assist you.
The undersigned Subscriber and Co-Subscriber hereby subscribe for and agree to purchase Shares at a purchase price of $0.05 per share for a total of $ (the “Subscription Amount”), all pursuant to the terms of the Prospectus.
When complete, please mail or deliver this duly executed Subscription Agreement and your Subscription Amount to:
PGI ENERGY FUND I SERIES 2010, Inc.
0000 Xxxxxxxxx Xxxx
Xxxxx 0000
Xxxxxxx, XX. 00000
Please make the check for your Subscription Amount payable to “PGI ENERGY FUND I SERIES 2010, Inc.”
I. SUBSCRIBER AND CO-SUBSCRIBER INFORMATION
| 1. | Subscriber Information: |
| Name of Subscriber:
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| Address:
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| Telephone No.:
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| Fax No.:
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| Email address:
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| Social Security No.:
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| Taxpayer ID No.:
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| Please check one of the following:
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¨ U.S. Citizen
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¨ U.S. Citizen residing outside the U.S. |
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| ¨ Resident Alien | ||||||
| ¨ Non-U.S. Citizen or Alien | ||||||
| ¨ Entity formed in the U.S. Specify domicile:
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| ¨ Non-U.S. entity | ||||||
| 2.Co-Subscriber | Information: |
| Name of Co-Subscriber:
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| Address:
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| Telephone No.:
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| Fax No.:
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| Email address:
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| Social Security No.:
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| Taxpayer ID No.:
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| Please check one of the following: |
¨ U.S. Citizen |
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| ¨ U.S. Citizen residing outside the U.S. |
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| ¨ Resident Alien |
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| ¨ Non-U.S. Citizen or Alien |
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| ¨ Entity formed in the U.S. Specify domicile:
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| ¨ Non-U.S. entity |
II. SUBSCRIBER AND CO-SUBSCRIBER ACKNOWLEDGEMENTS
The undersigned Subscriber and Co-Subscriber, if any, each acknowledge that:
| • | The Company reserves the right to unconditionally accept or reject Subscriber’s and an Co-Subscriber’s subscription for Shares, in whole or in part, and that (i) the Company will notify me whether my subscription is accepted or rejected and (ii) if such subscription is rejected, the Subscription Amount will be returned to me without deduction, interest or charge. |
| • | Subscriber and any Co-Subscriber acknowledge(s) that the Company reserves the right to accept or reject this subscription for any reason or for no reason. |
| • | Subscriber and any Co-Subscriber has/have received and read a copy of the Prospectus. |
| • | Subscriber, if a corporation, partnership, trust or other form of business entity, is authorized and otherwise duly qualified to purchase the Shares. The person(s) executing this Subscription Agreement, as well as all other documents related to the Offering, represent(s) that he, she, it, or they are duly authorized to execute all such documents on behalf of such entity. |
III. SIGNATURE(S) OF SUBSCRIBER AND CO-SUBSCRIBER
NOTE: BY EXECUTING THIS AGREEMENT, SUBSCRIBER DOES NOT HEREBY WAIVE ANY RIGHTS UNDER U.S. FEDERAL SECURITIES LAWS.
| Name of Subscriber: |
Signature: | |||
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| Date: | ||||
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| Name of Co-Subscriber: |
Signature: | |||
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| Date: | ||||
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IV. CAPACITY CLAIMED BY EACH SIGNER
1. Subscriber Capacity:
| ¿ | Individual |
| ¿ | Attorney-In-Fact |
| ¿ | Trustee |
| ¿ | Partner |
| ¿ | Guardian/Conservator |
| ¿ | Corporate |
| ¿ | Other: |
| Officer |
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2. Co-Subscriber:
| ¿ | Individual |
| ¿ | Attorney-In-Fact |
| ¿ | Trustee |
| ¿ | Partner |
| • | Guardian/Conservator |
| • | Corporate |
| • | Other: |
| Officer |
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[THE REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALLY.]
V. ACCEPTANCE OF SUBSCRIPTION BY COMPANY
The foregoing subscription is hereby accepted by PGI ENERGY FUND I SERIES 2010, Inc., on this day of 2010.
| PGI ENERGY FUND I SERIES 2010, INC. |
| By: |
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| Its: |
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| Name: |
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