SUBSCRIPTION FORM Registration: ____individual __joint tenants __tenants in common __custodian __trust ____ corporation ___________________________________ _________________________________________________________ First Name M.I. Last Name Soc. Sec....

									SUBSCRIPTION FORM

Registration:

 ____individual  __joint tenants  __tenants in common  __custodian  __trust   ____ corporation


____________________________________________________________________________________________
	First Name		M.I.		Last Name			Soc. Sec. Number

____________________________________________________________________________________________
	First Name		M.I.		Last Name			Soc. Sec. Number

___________________________________________________________If held for a beneficiary, please indicate				Street Address 				   the State of residence of the beneficiary.

______________________________________________________________________
	City				State		Zip Code

___ If cash make check payable to: Tensleep Financial Corporation

___ If debt enter amount ________________________

Amount Invested: Number of Units Purchased (Minimum 100 Units) _______ @ $25 per Unit = $___________.

Mail Check and Subscription to:	Tensleep Financial Corporation
				0000 Xxxxxxxxxx Xxxx
				Xxxxxxx Xxxxx, XX 00000

Dealer Information:

	Name of firm:		_____________________________________________

	Name of Representative:	_____________________________________________

	Address:		_____________________________________________

	Telephone: (____) ____________________

Company use only


Number of Units to be issued _________ Units rejected ____________



					Authorized Signature _________________________________



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