Subscription Agreement
8,000,000 Shares
Village XII Acquisition Corporation
To________________
Please issue shares of your common stock in the amounts and
name(s)shown below. My signature acknowledges that I have read the
Prospectus dated May 9, 2001, and am aware of the risk factors
contained therein. I represent that I have relied solely upon the
contents of the Prospectus in making an investment decision with
regard to the shares offered thereby, and I have not relied on any
other statements made by or with regard to the Company in connection
with its anticipated operations or financial performance.
The undersigned hereby acknowledges that First Union National
Bank is acting solely as Escrow Holder in connection with the offering
of the Securities described herein, and makes no recommendation with
respect thereto. First Union National Bank has made no investigation
regarding the offering, the issuer or any other person or entity
involved in the offering.
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(Signature) (Date)
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(Signature) (Date)
Enclosed is payment for __________ shares at $________;
Total: $_______
Register the shares in the following name(s) and amount(s):
(Please Print)
Name(s): _______________________________________________
Number of share(s): _______________
As (check one) [ ] Individual [ ] Joint Tenancy [ ]
Husband & Wife as community property [ ] Tenants in Common
[ ] Corporation [ ] Trust [ ] Other:
For the person(s) who will be registered shareowners:
Mailing Address:
City, State, Zip:
Telephone:
Social Security or Taxpayer ID Number(s):
Note: Please attach any instructions for mailing the certificates or
shareowner communications other than to the registered shareowner at
this address.
No Subscription Is Effective Until Acceptance.
Subscription Accepted by _______________________________________
__________________________________________________
Xxxxx Xxxxxxxx, President
Date: ____________________________________________
