SUBSCRIPTION AGREEMENT
Exhibit 4
0000,
Xxxxx
Xxxxxxxxx
(Xxxxxx)
Xxxxxx
X0X 0X0
The
undersigned has received the prospectus dated __________, 2010 (“Prospectus”),
and hereby subscribes for _____________ shares of $.001 par value common stock
of Plycrete, Inc., a Nevada corporation (“Company”), for a subscription price of
$0.30 per share (“Offered Shares”). The undersigned hereby agrees
that this subscription shall be irrevocable and shall survive the death or
disability of the undersigned. Payment of the purchase price for the
Offered Shares is due upon subscription.
The
undersigned acknowledges that (i) the Company has the right to accept or reject
this subscription in whole or in part, (ii) this subscription shall be deemed to
be accepted by the Company only when the Company signs this Subscription
Agreement; and (iii) the undersigned has relied only on that information
specified in the Prospectus.
Number of
Offered Shares: _________________. Subscription Amount: ___________
(number of Offered Shares multiplied by $0.30)
Make
check payable
to: “Plycrete, Inc.”
Please
print name(s) or title, residence address, and SSN or Tax ID for which the
Offered Shares are to be registered. Please notify the Company in
writing if your address changes before you either receive your shares or are
notified that your subscription has not been accepted.
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Name
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Street
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City
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State
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Zip
Code
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SSN
or Tax ID No. (For joint ownership, both parties must provide a Social Security
Number or similar tax identification)
Indicate
type of ownership:
| o |
Individual
Ownership
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o |
Joint
Tenants with Right of Survivorship
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| o |
Community
Property
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o |
Tenants
in Common
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| o |
Tenants
by the Entirety
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o |
Corporate
Ownership
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| o |
Partnership
Ownership
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o |
Custodian
for a Minor
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| o |
Trust
(see below)
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o |
XXX
or Pension Plan
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Date
Trust Established:
Name of
Trustee or other Administrator
1
Each
subscriber represents that:
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(a)
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The
information contained herein is complete and accurate and may be relied
upon, and
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(b)
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The
undersigned will notify the Company immediately of any material change in
any such information occurring prior to the acceptance of the
undersigned’s subscription, including any changes in address or other
contact information.
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IN
WITNESS WHEREOF, the undersigned has executed this Subscription Agreement as of
this ______ day of ____________ 2010.
FOR
INDIVIDUALS:
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Print
Name
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Signature
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NAME
AND SIGNATURE OF JOINT TENANT OR TENANT IN COMMON
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Print
Name
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Signature
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FOR
TRUSTS, CORPORATIONS, PARTNERSHIPS
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Print
Name of Entity
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By:
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| Print name and capacity (Trustee, President or General Partner) of person making investment decision | ||
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Signature
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Agreed to
and accepted:
By: Plycrete,
Inc.,
a Nevada corporation
By: ______________________
Xxxxxxx
Xxxxxxxxxx
Its: President
2
