PRELIMINARY SUBSCRIPTION AGREEMENT
Exhibit 4.5
Xxxx Security International, Inc.
000 Xxxxxxxxx Xxxx, Xxxxx 000
Xxxxxxx, Xxxxxxxxxxxx 00000
Attention: Xxxxxxx Xxxxxxxx
000 Xxxxxxxxx Xxxx, Xxxxx 000
Xxxxxxx, Xxxxxxxxxxxx 00000
Attention: Xxxxxxx Xxxxxxxx
Ladies and Gentlemen:
I hereby subscribe to purchase the number of shares of Common Stock (the “Shares”) of Xxxx
Security International, Inc. (the “Company”) indicated below. I have received a copy of the
Company’s prospectus, dated [ ], 2011. I understand that my purchase of the Company’s stock
involves significant risk, as described under “Risk Factors” in the prospectus. I also understand
that no federal or state agency has made any finding or determination regarding the fairness of
the Company’s offering of the shares, the accuracy or adequacy of the prospectus, or any
recommendation or endorsement concerning an investment in the shares.
I am not sending the purchase price for the Shares I wish to buy at this time. After I receive the
prospectus supplement announcing the results of the Company’s rights offering to its shareholders,
if I still wish to purchase Shares, I will send the Company an acknowledgment of subscription and
a check in the amount of $[ ] multiplied by the number of Shares I wish to buy. My check
will be made payable to “American Stock Transfer & Trust
Company, LLC”
WHEN THE COMPANY RECEIVES MY ACKNOWLEDGMENT OF SUBSCRIPTION AND MY CHECK, THIS SUBSCRIPTION
AGREEMENT WILL BECOME FINAL AND BINDING AND WILL BE IRREVOCABLE UNTIL THE OFFERING IS CLOSED.
NUMBER OF
SHARES ____________________
TOTAL SUBSCRIPTION PRICE (AT $[ ] PER SHARE): $____________________
( DO NOT SEND THE PURCHASE PRICE FOR YOUR SHARES AT THIS TIME)
TOTAL SUBSCRIPTION PRICE (AT $[ ] PER SHARE): $____________________
( DO NOT SEND THE PURCHASE PRICE FOR YOUR SHARES AT THIS TIME)
PLEASE PRINT OR TYPE EXACT NAME(S) IN WHICH UNDERSIGNED DESIRES SHARES TO BE REGISTERED:
_________________________
_________________________
TYPE OF ENTITY, IF NOT A PERSON:_________________________*
SOCIAL SECURITY OR FEDERAL TAXPAYER IDENTIFICATION NO. __________________
* | When signing as attorney, trustee, administrator, or guardian, please give your full title as such. If a corporation or other entity, please sign in full corporate name by president or other authorized officer. In case of joint tenants, each joint owner must sign. |
SUBSTITUTE W-9
Under penalty of perjury, I certify that: (1) the Social Security number or Taxpayer Identification
Number given above is correct; and (2) I am not subject to backup withholding.
INSTRUCTION: YOU MUST CROSS OUT (2) ABOVE IF YOU HAVE BEEN NOTIFIED BY THE INTERNAL REVENUE SERVICE
THAT YOU ARE SUBJECT TO BACKUP WITHHOLDING BECAUSE OF UNDERREPORTING INTEREST OR DIVIDENDS ON YOUR
TAX RETURN.
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TO BE COMPLETED BY THE COMPANY
Accepted as of ,2011, as to shares.
XXXX SECURITY INTERNATIONAL, INC.
By: |
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Title: Chief Financial Officer |
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