ELSINORE SERVICES, INC. SUBSCRIPTION AGREEMENT
Exhibit
10.1
ELSINORE
SERVICES, 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, $.001 par value per share (“Common Stock”), of Elsinore Services, Inc., a
Delaware 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, dated _________, 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 3,000,000 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 Xx.
Xxxx Xxxxxx, Chief Executive Officer, or Xx. Xxxx Xxxxxxx, Chief Financial
Officer, of the Company at 0000 Xxxxxxxxxxxxx Xxxxx, X.X. Xxxxx 0X-000,
Xxxxxxxxxx, X.X. 00000-0000 or by telephone at (000) 000-0000, and one or both
will assist you.
The
undersigned Subscriber and Co-Subscriber hereby subscribe for and agree to
purchase _______________ Shares at a purchase price of $0.02 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:
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Elsinore
Services, Inc.
0000
Xxxxxxxxxxxxx Xxxxx, X.X.
Xxxxx
0X-000
Xxxxxxxxxx,
X.X. 00000-0000
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Please make the check for your
Subscription Amount payable to “Elsinore Services,
Inc.”
I. SUBSCRIBER AND CO-SUBSCRIBER
INFORMATION
1. Subscriber
Information:
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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
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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
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2. Co-Subscriber
Information:
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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:
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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
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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
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II.
SUBSCRIBER AND CO-SUBSCRIBER ACKNOWLEDGEMENTS
The
undersigned Subscriber and Co-Subscriber, if any, each acknowledge
that:
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·
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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.
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·
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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.
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·
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Subscriber
and any Co-Subscriber has/have received and read a copy of the
Prospectus.
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·
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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.
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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.
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Name of Subscriber:
____________________________
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Signature:
_____________________________________
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Date:
_________________________________________
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Name of Co-Subscriber:
_________________________
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Signature:
_____________________________________
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Date:
_________________________________________
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IV.
CAPACITY CLAIMED BY
EACH SIGNER
1. Subscriber
Capacity:
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Individual
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Attorney-In-Fact
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Trustee
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Partner
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Guardian/Conservator
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Corporate
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Other:
______________________________
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Officer
_____________________________
_____________________________
2. Co-Subscriber:
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Individual
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Attorney-In-Fact
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Trustee
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Partner
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Guardian/Conservator
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Corporate
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Other:
______________________________
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Officer
_____________________________
_____________________________
[THE
REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALLY.]
V.
ACCEPTANCE OF
SUBSCRIPTION BY COMPANY
The
foregoing subscription is hereby accepted by Elsinore Services, Inc., on this
______ day of 2010.
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ELSINORE
SERVICES, INC.
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By:
______________________________________
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Its:
______________________________________
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Name:
___________________________________
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