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Exhibit 10(i)(d)
CAUTION: THIS FORM IS ONLY FOR USE BY RESIDENTS OF AZ, FL, NC AND TX. RESIDENTS
OF AK, DC, HI, ID, MT, NE, NM, ND, RI, SD, UT, VT, WA, AND WY ARE NOT PERMITTED
TO PURCHASE SHARES IN THIS OFFERING. RESIDENTS OF ALL OTHER STATES MUST USE A
DIFFERENT FORM.
INSTRUCTIONS TO
BROKER/DEALER INVESTOR SUBSCRIPTION AGREEMENT
FOR
FANZ ENTERPRISES, INC.
Persons interested in purchasing shares of Common Stock, $.01 par value
per share, ("Shares") of FanZ Enterprises, Inc. (the "Company") must :
1. FULLY complete and sign the attached Subscription Agreement (the
"Agreement");
PLEASE COMPETE THE ENTIRE FORM. INCOMPLETE FORMS WILL BE
RETURNED TO YOU.
2. Include a check made payable to "FIRSTAR BANK, N.A., ESCROW ACCOUNT
FOR FANZ ENTERPRISES, INC." (Please note the minimum amount of
$250.00.)
3. Send the completed and signed AGREEMENT AND CHECK to:
FanZ Enterprises, Inc.
0000 Xxxxxx Xxxxx
Xxxxxx, XX 00000
Once the Company receives your executed Agreement and check, the check
will be sent to the escrow agent for processing and the Agreement will be sent
to our broker/dealer _____________________ at _______________. The broker/dealer
will contact you to verify the accuracy of your responses and to answer any
question that you may have regarding the Offering. If and when accepted, the
Agreement shall constitute a subscription for Shares of the Company. THE MINIMUM
INVESTMENT IS $250.00 (25 SHARES).
The Company and the broker/dealer reserve the right to reject in its
entirety any subscription that is tendered or to allocate to any prospective
purchaser a smaller number of Shares than the prospective purchaser has
subscribed to purchase. In such event, the broker/dealer will return to you the
Agreement and the Company will return your payment (or a pro rata portion of
your payment, if subscription is rejected only in part), with interest if your
check or funds are deposited in the escrow account.
A copy of the accepted Agreement will be returned to you as your
receipt, and a stock certificate will be issued to you shortly thereafter.
PLEASE COMPLETE AND RETURN THE
ATTACHED PAGE WITH YOUR CHECK
NOTE: Before completing the attached subscription agreement, you should
carefully and completely read the Company's Prospectus. In making
your investment decision, you should rely only on the information
in the Company's Prospectus and not on any other information.
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BROKER/DEALER INVESTOR SUBSCRIPTION AGREEMENT
FOR
FANZ ENTERPRISES, INC.
I/we hereby irrevocably tender this Agreement for the purchase of
_________ Shares (25 SHARES MINIMUM) at $10.00 per Share. With this Agreement,
I/we tender payment in the amount of $_______ ($10.00 per Share; $250.00 MINIMUM
INVESTMENT) for the Shares subscribed.
In connection with this investment in the Company, I/we represent and
warrant as follows:
a. Prior to tendering payment for the Shares, I/we received the Company's Prospectus dated
___________________ 2001.
b. I am/we are bona fide resident(s) of , .
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(State) (Country)
c. RESIDENTS OF AR, NC AND TX: I/we HAVE / DO NOT HAVE (please circle one) either (i) an annual gross
income of $65,000 or more and a minimum net worth of $65,000 (excluding the value of automobiles,
homes and home furnishings) OR (ii) a minimum net worth of $150,000 (excluding the value of
automobiles, homes and home furnishings).1
Form/Type of Ownership for Shares Being Purchased ( MUST check one):
___ Individual ___ Minor with adult custodian ___ Tenants-in-Common
___ Existing Partnership under the Uniform Gift ___ Joint Tenants
___ Corporation To Minors Act ___ Trust
For the person(s) who will be registered shareholder(s) (MUST FULLY COMPLETE):
Name of shareholder as you would like it to appear on stock certificate:
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Name(s): Telephone:
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Street Address:
------------------------------------------------- Social Security or
Taxpayer ID No.:
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City: State: Zip: Date of Birth:
----------------------- ---- ------------ -----------------------------
Signature: Date:
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ACCEPTED BY: FANZ ENTERPRISES, INC.
By: Title: Date:
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Method of Payment: ________________________ Item No. ____________________
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(1) The state securities agencies of Arizona, Florida, North Carolina and Texas
require that residents may only purchase Shares through a broker/dealer licensed
with the state. Additionally, Arizona, North Carolina and Texas have restricted
the sale of these securities to only residents of these states who meet the
sophistication requirements of the North American Securities Administrators
Association. Residents of Arizona, North Carolina and Texas who do not meet the
income / net worth requirements in section (c) above may NOT purchase Shares at
this time.