SUBSCRIPTION AGREEMENT
Exhibit
10.17
To
U.S. Dry Cleaning Corporation:
I
am a
resident of the State of California. I hereby certify that, by checking the
applicable box below, I meet the suitability standard described:
PLEASE
CHECK AT LEAST ONE:
| o |
I
currently have a liquid net worth, meaning a net worth exclusive
of home,
home furnishings and automobile, of at least $250,000) plus estimated
$65,000 gross income during the current tax
year
|
| o |
I
currently have a liquid net worth, meaning a net worth exclusive
of home,
home furnishings and automobile, of at least $500,000
|
| o |
I
currently have a net worth inclusive of home, home furnishings and
automobiles, of at least $1,000,000
|
| o |
I
currently have an annual gross income of at least
$200,000
|
I
understand that U.S. Dry Cleaning Corporation and the underwriters will be
relying on the above representations by me.
I
enclose
herewith $____________ as payment for ___________ Units at $______ per Unit
in
the pending public offering of U.S. Dry Cleaning Corporation. Please issue
my
Units in following name(s):
(Please
Print)
Name(s):
___________________ ___________________ ___________________
As:
(check one)
¨
Individual
¨
Joint
Tenancy ¨
Husband
& Wife as community property
¨
Tenants
in Common ¨Corporation
¨
Trust
¨
Other:
______________________________________________
My
mailing address is:
(P.O.
Box
not acceptable): ___________________________________________
City:
____________________________________ State: ______ Zip/Post Code:
______
Home
Phone: ______________________ Work Phone: _________________________
Social
Security or Taxpayer ID Number(s): ________________
__________________
******************************************
No
subscription is effective until accepted by the underwriter and the issuer.
The
undersigned understands that this subscription may be accepted or rejected
in
whole or in part by the underwriter or the issuer in their sole discretion
and
that this subscription is and shall be irrevocable the underwriter or the issuer
for any reason reject this subscription.
*******************************************
______________________________________ _______________________________
Subscriber
Signature Date
______________________________________ _______________________________
Subscriber
Signature Date
Subscription
Accepted by Underwriter:
______________________________________ ________________________________
BY:
Date
ITS:
Subscription
Accepted by U.S. Dry Cleaning Corporation:
___________________________________________ _______________________
BY:
Xxxxxx X. Xxx Date
ITS:
Chief Executive Officer
