EXHIBIT 99.3
FORM OF
SUBSCRIPTION AGREEMENT
OFFERING SUBSCRIPTION AGREEMENT
FIRST NATIONAL COMMUNITY BANCORP, INC.
75,000 Shares
Common Stock
(Par value $1.25 Per Share)
Minimum Subscription: $1,000.00
Maximum Subscription: $250,000.00
Price Per Share: $40.00
First National Community Bancorp, Inc.
000 Xxxx Xxxxxxx Xxxxxxx
Xxxxxxx, Xxxxxxxxxxxx 00000-0000
Attn: J. Xxxxx Xxxxxxxx, President
Gentlemen:
1. I/We subscribe for and agree to purchase the number of shares of common
stock of First National Community Bancorp, Inc. (the "Company") in connection
with the offering, upon the terms and conditions provided herein and in the
Company's prospectus dated October 22, 1999, and any supplements to the
Company's prospectus, as follows:
No. of Shares Price Per Share Purchase Price
($1,000.00 Minimum)
($250,000.00 Maximum)
x $40.00 = $
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2. Method of Payment (Check One)
______ I/We enclose our check, bank draft or money order made payable,
in United States currency, to the order of "First National
Community Bancorp, Inc.," for the amount of the purchase price,
as calculated in Paragraph 1, above.
______ I/We authorize withdrawal from this (these) account(s) at First
National Community Bank for the amount of the purchase price, as
calculated in Paragraph 1, above.
Account Number(s) Amount
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$
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$
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$
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Total Amount to be Withdrawn $
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3. Stock Registration (Please type or print the information requested
below.)
__________________________________________
Name(s) in which stock is to be registered Day Phone (___) _______________
__________________________________________
Name(s) in which stock is to be registered Evening Phone (___) _______________
The manner of ownership shall be (check one):
__________________________________________ [ ] Individual
Title, if applicable, of Subscriber [ ] Tenants by the entireties (each must sign)
[ ] Joint Tenants with right of survivorship
(each must sign)
__________________________________________ [ ] Tenants in Common (each must sign)
Title, if applicable, of Co-Subscriber [ ] In Partnership
[ ] As custodian, trustee or agent for _______
__________________________________________ [ ] Corporation
Street Address of Subscribers
________________________________________________________________________________
City County State Zip Code
___________________________________________________
Social Security or Tax I.D. Number of Subscriber
___________________________________________________
Social Security or Tax I.D. Number of Co-Subscriber
4. The Company has the right to accept or reject any subscription, in whole
or in part, for any reason whatsoever.
5. I/We may not revoke this agreement. I/We understand that there is no
aggregate minimum number of shares of common stock that the Company must sell
pursuant to the offering. I/We understand and agree that there shall be no
refund of any portion of the purchase price paid pursuant to this agreement
unless and until the Company rejects the subscription.
6. The Company will send any refund checks to the address specified above.
The Company will register all shares of common stock in the name(s) of, and send
them to the address specified above.
7. This agreement shall be accepted and become an agreement binding on the
Company, only if and when executed in the name and on behalf of the Company and
when notice of the execution and acceptance (which may be a copy or similar
counterpart hereof) is mailed to the subscriber(s). This agreement is binding,
after acceptance by the Company, upon the heirs, estate, legal representatives,
assigns and successors of the subscribers and shall survive the death,
disability or dissolution of them.
8. I/We have received, read and understood the Company's prospectus dated
October 22, 1999, and any supplements to the prospectus. I/We understand that
this
representation does not constitute a waiver of any rights under the Securities
Act of 1933, the Securities Exchange Act of 1934 or under the Pennsylvania
Securities Act of 1972 and the rules and regulations adopted thereunder. I/We
understand that an investment in the common stock includes certain risks, and
have carefully read and considered the matters set forth under the caption "Risk
Factors" and elsewhere in the prospectus. I/We have not received information or
representations that are either inconsistent with or undisclosed in the
prospectus. I/We acknowledge and understand that no federal or state agency has
made any finding or determination as to the fairness for public investment, nor
any recommendation or endorsement of the shares.
9. The offering will terminate at 5:00 p.m. on November 30, 1999, or at
such later date as shall be determined by the Company, but in no event later
than 5:00 p.m. on December 17, 1999.
10. I/We represent that I/we am/are at least eighteen (18) years of age.
11. I/We agree not to transfer or assign this agreement, or any interest in
this agreement, including, but not limited to, the common stock purchased
through this subscription, except in accordance with all applicable laws.
12. I/We acknowledge that the shares of the Company's common stock are not
deposits. These securities are not insured by the Federal Deposit Insurance
Corporation or any other governmental agency and are subject to investment risk,
including the possible loss of principal. Furthermore, an investment in the
shares of the Company's common stock is not guaranteed by the Company.
13. If this agreement is executed on behalf of a corporation, partnership,
trust or other entity, I/we have been duly authorized to execute this agreement
and all other instruments in connection with the purchase of the common stock,
and my/our signature(s) is/are binding upon the corporation, partnership, trust
or other entity. The Company retains the right to request the production of an
appropriate certification for this authorization.
14. The provisions of this agreement shall be construed and enforced
according to the laws of the Commonwealth of Pennsylvania. In the event there is
any conflict between the prospectus and this agreement, the terms set forth in
the prospectus and any supplements to the prospectus shall be controlling.
15. This agreement constitutes the entire agreement among the parties with
respect to the subject matter of this agreement and may be amended only by a
writing executed by the party to be bound.
Dated:
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(Signature of Subscriber)
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(Print Name)
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(Signature of Co-Subscriber)
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(Print Name)
Accepted:
FIRST NATIONAL COMMUNITY BANCORP, INC.
By:
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(Authorized Signature)
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(Date of Execution)
