PURCHASE ORDER FORM (Subscription Agreement)
EXHIBIT 99.1
PURCHASE ORDER FORM
Premier Indemnity Holding Company
0000 Xxxxx Xxxxx Xxxxx Xxxxx, Xxxxx 000
Xxxxx, Xxxxxxx 00000
Dear Sirs:
The undersigned (the “Purchaser”) acknowledge that I have received and reviewed the Prospectus of Premier Indemnity Holding Company, dated__________ 2006.
Concurrent with execution of this Agreement, the Purchaser is purchasing _______________________________________________ (__________) shares of Common Stock of Premier Indemnity Holding Company, a Florida corporation (the “Company”) at a price of $1.00 per Share (the “Subscription Price”). Purchaser hereby confirms the subscription for and purchase of said number of shares and hereby agrees to pay herewith the Subscription Price for such Shares.
Purchaser further confirms that ________________________________________________solicited him/her/it to purchase the shares of Common Stock of the Company and no other person participated in such solicitation other than such person(s).
Purchaser has: (1) reviewed the prospectus; (2) identified the person(s) who solicited the purchase; and (3) that the persons identified were the only persons who solicited the purchase. All of the above and Purchaser’s execution of this Form does not in any way constitute waivers of the purchaser’s rights under the federal securities laws.
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MAKE CHECK PAYABLE TO: PREMIER INDEMNITY HOLDING COMPANY |
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Executed this _____ day of ___________________, 2006. |
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__________________________________ |
_______________________________________ |
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__________________________________ |
Signature of Purchaser |
__________________________________
Address of Purchaser
__________________________________
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Printed Name of Purchaser |
PLEASE ENSURE FUNDS ARE IN US DOLLARS
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_____________ |
X $1.00 |
___________ |
= |
US$ |
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Number of Shares Purchased |
Total Subscription Price | ||||||
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Form of Payment: |
Cash:_______ |
Check #: _________________Other: ______________________ |
PREMIER INDEMNITY HOLDING COMPANY
By: ________________________________________ Title: ______________________________________
