ORGANIC XXXX.XXX, INC. - COMMON STOCK
SUBSCRIPTION AGREEMENT
Investment
I desire to purchase __________ shares of Organic Xxxxx.Xxx, Inc at $1.50 per
share for a total of $ __________.
Make Checks Payable to: Organic Xxxxx.Xxx, Inc.
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):
FORM OF OWNERSHIP (HOW THE INVESTMENT SHOULD BE TITLED):
INVESTOR RESIDENCE ADDRESS 1:
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CHECK ONE OF THE FOLLOWING:
____ U.S. Citizen
____ Resident Alien
____ U.S. Citizen residing outside the U.S.
____Non-resident Alien
INVESTOR RESIDENCE ADDRESS 2:
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CHECK ONE OF THE FOLLOWING:
____ U.S. Citizen
____ Resident Alien
____ U.S. Citizen residing outside the U.S.
____Non-resident Alien
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,
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)
Investor No. 1
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Investor No. 2
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Subscriber Signature: The undersigned has the authority to enter into this
subscription agreement on behalf of the person(s) or entity registered above. By
signing this subscription agreement, the undersigned acknowledges that he/she/it
has read the Prospectus and understands the risks associated with this
investment.
Authorized Signature of Investor 1____________________Date:__________________
Authorized Signature of Investor 2____________________Date:__________________
Company's Acceptance (To be completed only by an authorized representative of
the Company.)
The foregoing subscription is accepted this ______ day of____________, _____
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Authorized Representative of the Company
