EXHIBIT 99.1
PURADYN FILTER TECHNOLOGIES INCORPORATED
SUBSCRIPTION AGREEMENT FOR COMMON STOCK
Puradyn Filter Technologies Incorporated
0000 Xxxx Xxxxx Xxxx
Xxxxxxx Xxxxx, Xxxxxxx 00000
Ladies and Gentlemen:
I desire to purchase _____________________shares of Puradyn Filter
Technologies Incorporated (the "Company") at $[ ] per share for a total
investment of $------------------- pursuant to the terms of the prospectus dated
[ ], 200_. Accompanying this subscription is the undersigned's check in the full
amount of the subscription payable to "Puradyn Filter Technologies
Incorporated." The undersigned represents to the Company that it has received
and read the Company's prospectus dated [ ], 200_ and that the undersigned has
the authority to enter into this subscription agreement on behalf of the
person(s) or entity registered above.
The Shares are to be issued in ____________________________________________
(check one box): Print Name of Investor
|_|____ individual name ____________________________________________
Print Name of Joint Investor (if applicable)
|_|____ joint tenants with rights of survivorship
____________________________________________
|_|____ tenants in entirety Signature of Investor
|_|____ corporation (an officer must sign) ____________________________________________
Signature of Joint Investor
|_|____ partnership (all general partners must sign)
____________________________________________
Print Name of Corporation, Partnership or
other Institutional Investor
By:_________________________________________
Title:______________________________________
Investor's complete address:
(Street)
(City) (State) (Zip) (Country)
Please check one of the following |_| U.S. Citizen
|_| U.S. Citizen residing outside the U.S.
|_| Resident Alien
|_| Non-U.S. Citizen
|_| Entity formed in the U.S. (specify domicile:_______)
|_| Non-U.S. Entity
Social Security Number (if individual investor)
Taxpayer Identification Number (if applicable)
Accepted as of this ______________ day of ______________ 200__
Puradyn Filter Technologies Incorporated
By:________________________________
Xxxxxx X. Xxxxxxxx, Chairman and CEO
