SILICON SOUTH, INC. - COMMON STOCK
SUBSCRIPTION AGREEMENT
Investment
I desire to purchase shares of
Silicon South, Inc at $0.50 per share for a total of $
MAKE CHECKS PAYABLE TO: ESCROW SPECIALISTS, SILICON SOUTH, INC., ESCROW
ACCOUNT
Subscriber Information: Please clearly print name(s) in which Shares are to be
acquired. All correspondence will go to the Investor Residence Address
Investor 1 (First, Middle I., Last):
Investor 2 (First, Middle I. Last):
Registration for the Investment (how the investment should be titled):
Check one of the following:
U.S. Citizen
Resident Alien
Foreign Resident; Country ________
U.S. Citizen residing outside the U.S.
Investor Residence Address 1:
Investor Residence Address 2:
City, State ZIP Code
Enter the taxpayer identification number. For most individual taxpayers, it is
their Social Security Number. Note: If the purchase is in more than one name,
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the number should be that of the first person listed. For IRAs, Keoghs, and
qualified plans, enter both the Social Security Number and the Taxpayer
Identification Number for the plan.
Social Security Number
Taxpayer Identification Number(if applicable)
Form of Ownership (Individual, XXX, Trust, UGMA, Pension Plan, etc.)
Subscriber Signature: The undersigned has the authority to enter into this
subscription agreement on behalf of the person(s) or entity registered above.
Authorized Signature of Investor 1 ________________________________________
Date:_____________________________________
Authorized Signature of Investor 2 ________________________________________
Date:_____________________________________
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Company's Acceptance (To be completed only by an authorized representative of
the Company.)
The foregoing subscription is accepted this ____________ day of
________________, _____
___________________________________
Authorized Representative of the
Company
