Subscription Attachment
I, _____________, hereby agree to purchase the following shares of stock
in Physicians Care for Connecticut, Inc. (the "Company") on the terms and
conditions set forth below and in the Company's Prospectus dated ________
("Prospectus"):
A. Primary Care Physicians (See definition of Primary Care Physician
("PCP") contained on page 48 of the Prospectus):
1 Class A shares: (Note: PCPs may only purchase 1 share of Class A
stock)
@ $3,000 per share if shares purchased before _____ $_________
@ $4,000 per share if shares purchased after ______ $_________
___ Class B shares: (Note: PCPs may purchase as many Class B shares
as desired but are not required to purchase any Class B shares)
@ $3,000 per share if shares purchased before _____ $_________
@ $4,000 per share if shares purchased after ______ $_________
Total: $_________
B. Specialist Physician (See definition of Specialist Physician contained
on page 48 of the Prospectus):
1 Class A shares: (Note: Specialists may only purchase 1 share of
Class A stock)
@ $3,000 per share if shares purchased before _____ $_________
@ $4,000 per share if shares purchased after ______ $_________
Total: $_________
___ Class B shares: (Note: Specialists must purchase at least one share of
Class B stock; however, after purchasing a share of Class B stock,
Specialists may purchase as many Class B shares as desired)
@ $3,000 per share if shares purchased before ____ $_________
@ $4,000 per share if shares purchased after ______ $_________
C. Hospital Investors.
___ Class B shares: (Note: Hospitals may not purchase Class A shares)
(Note: Licensed hospitals are required to purchase not less than
62.50 shares of Class B stock at $4,000 dollars per share, provided,
however, that if a validly licensed hospital has less than 100 beds,
then the Hospital is required to purchase not less than 25 shares of
Class B stock at $4,000 per share.)
$________
Total: $________
I acknowledge and agree that my purchase of the shares of the Company's
stock indicated above is subject to the terms, conditions, restrictions,
limitations and obligations set forth in the Prospectus.
Please read, complete and sign this Subscription Attachment and return the
Subscription Attachment to:
Physicians Care for Connecticut, Inc.
c/o MedServ IPA, Inc.
0000 Xxxxxxxx Xxxxxx
Xxxxxxxx, Xxxxxxxxxxx 00000
Attn: Stock Subscription
This Subscription Attachment should be returned to Physicians Care for
Connecticut, Inc. along with the following:
- If applying for a loan from Fleet National Bank, the loan
application form and an executed.
- A MedServ IPA Participation Agreement and the attached Physicians
Care for Connecticut Primary Care Physician or Specialist
Physician Attachment.
- A check or money order payable in good funds in U.S. dollars and
drawn on a bank in the United States in an amount equaling the
purchase price calculated above.
__________________________
Signature
__________________________
Date
Acknowledged and Accepted:
Physicians Care for Connecticut, Inc.
By:_______________________
__________________________
Date
