Exhibit 1.1
SUBSCRIPTION AGREEMENT
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XXXXXX.XXX, INC.
SUBSCRIPTION AGREEMENT - COMMON SHARES
Gentlemen: The Investor named below, by payment of the purchase price for such
Common Shares, by the delivery of a check payable to XXXXXX.XXX, INC., hereby
subscribes for the purchase of the number of Common Shares indicated below
(minimum of one hundred) of XXXXXX.XXX, INC., at a purchase of $2.50 per Share
as set forth in the Prospectus. By such payment, the named Investor further
acknowledges receipt of the Prospectus and any Supplement and the Subscription
Agreement, the terms of which govern the investment in the Common Shares being
subscribed for hereby.
A. INVESTMENT: (1) Number of Shares ___________
(2) Total Contribution ($2.50/Share) $_______________
(3) Initial Purchase [ ] Additional Purchase [ ]
Date of Investor's check___________________
B. REGISTRATION:
(4) Registered owner:_____________________________
Co-Owner: ____________________________
(5) Mailing address: _____________________________
City, State & zip: ____________________________
(6) Residence Address (if different from above):
__________________________________________________
__________________________________________________
(7) Birth Date: ___________/___________/____________
(8) Employee or Affiliate: Yes__________No___________
(9) Please indicate Citizenship Status: _________________
(10) Social Security:
#:_____________/_____________/_______________
U.S. Citizen [ ] Other [ ]
Co-Owner Social Security:
#:_________________/_____________/_______________
(11) Telephone (H) ( ) ______________________
Corporate or Custodial: ____________/___________/____________
Taxpayer ID #: ______-______________/______________
C OWNERSHIP [ ] Individual Ownership [ ] XXX or Xxxxx
[ ] Joint Tenants with Rights of Survivorship
[ ] Trust/Date Trust Established_______________
[ ] Pension/Trust (S.E.P.) [ ]Tenants in Common
[ ] Tenants by the Entirety [ ] Corporate Ownership
[ ] Partnership [ ]Other_____________________
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D. SIGNATURES: By signing below, I/we represent that I/we meet the suitability
standards set forth in the Prospectus under "Suitability Standards." Signatures
- Registered
Owner:_______________________________________
Co-Owner:____________________________________
Print Name of Custodian or Trustee:______________________________________
Authorized Signature:___________________________
Date:_____________________ Witness _______
Signature_____________________________________
E. PAYMENT SHOULD BE SENT TO (IF DIFFERENT THAN REGISTERED OWNER):
Name:____________________________________________________
c/o_______________________________________________________
Address:__________________________________________________
Account Number:___________________________________________
City, State & Zip:____________________________________________
Telephone Number:_________________________________________
F: BENEFICIAL OWNER(S): All reports and financial statements will normally be
sent to the registered owner at the address in Section B. If reports and
financial statements are to be sent to the Beneficial Owner of an XXX or Xxxxx,
insert name of the Beneficial Owner.
Name of Beneficial Owner Only:_______________________________
Telephone Number:_________________________________________
Address:_________________________________________________
City, State & Zip:___________________________________________
G. BROKER-DEALER/REGISTERED REPRESENTATIVE DATA: ALL LINES MUST BE COMPLETED,
ANY MISSING SIGNATURES MAY DELAY PROCESSING OF THIS ORDER.
Broker-Dealer NASD Firm Name:________________________________
Date:_______________ Telephone Number:_______________________________
Main Office Address:______________________________________
City, State &Zip:________________________________________________
Print or Type Name of Broker-Dealer, Principal or other Authorized
Signatory:______________________________________________________
Authorized Signature:_____________________________________________
Print or Type Name of Registered Representative or other Authorized
Signatory:________________________________________________________
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Signature:________________________________________________________
Branch Office Address:_____________________________________
City, State & Zip:________________________________________
MAIL TO: XXxxxx.xxx, Inc., 000 Xxxxxxx Xxxxxx, Xxxxx 0x, Xxxxxxxx, Xxxxxxxxxxx
00000 telephone 203/000-0000, facsimile 203/602-9995.
OFFICE USE ONLY:
Date Received:__________________________________
Date Accepted/Rejected_________________________________________
Subscriber's Check Amount:_______________________
Check No.___________________ Date Check ________________
Deposited________________________________
MR #________________
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