SUBSCRIPTION AGREEMENT
Exhibit 4.1
The Graystone Company, Inc.
000 Xxxxxxxxx Xxx
00xx Xxxxx
Xxx Xxxx, Xxx Xxxx 00000
The undersigned has received the prospectus dated __________, 2011 (“Prospectus”), and hereby subscribes for _____________ shares of $.0001 par value common stock of The Graystone Company, Inc., a Delaware corporation (“Company”), for a subscription price of $_____ per share (“Offered Shares”). The undersigned hereby agrees that this subscription shall be irrevocable and shall survive the death or disability of the undersigned. Payment of the purchase price for the Offered Shares is due upon subscription.
The undersigned acknowledges that (i) the Company has the right to accept or reject this subscription in whole or in part, (ii) this subscription shall be deemed to be accepted by the Company only when the Company signs this Subscription Agreement; and (iii) the undersigned has relied only on that information specified in the Prospectus.
Number of Offered Shares: _________________. Subscription Amount: ___________ (number of Offered Shares multiplied by $____)
Send wires to: “The Graystone Company, Inc.”
(wire instructions will forward to you upon the acceptance of your subscription agreement by the Company.
Please print name(s) or title, residence address, and SSN or Tax ID for which the Offered Shares are to be registered. Please notify the Company in writing if your address changes before you either receive your shares or are notified that your subscription has not been accepted.
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Name
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Street
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City
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State
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Zip Code
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SSN or Tax ID No. (For joint ownership, both parties must provide a Social Security Number or similar tax identification)
Indicate type of ownership:
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o
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Individual Ownership
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o
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Joint Tenants with Right of Survivorship
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o
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Community Property
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o
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Tenants in Common
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o
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Tenants by the Entirety
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o
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Corporate Ownership
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o
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Partnership Ownership
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o
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Custodian for a Minor
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o
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Trust (see below)
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o
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XXX or Pension Plan
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Date Trust Established:
Name of Trustee or other Administrator
Each subscriber represents that:
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(a)
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The information contained herein is complete and accurate and may be relied upon, and
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(b)
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The undersigned will notify the Company immediately of any material change in any such information occurring prior to the acceptance of the undersigned’s subscription, including any changes in address or other contact information.
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IN WITNESS WHEREOF, the undersigned has executed this Subscription Agreement as of this ______ day of ____________ 2011.
FOR INDIVIDUALS:
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Print Name
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Signature
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NAME AND SIGNATURE OF JOINT TENANT OR TENANT IN COMMON
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Print Name
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Signature
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FOR TRUSTS, CORPORATIONS, PARTNERSHIPS
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Print Name of Entity
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By:
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Print name and capacity (Trustee, President or General Partner) of person making investment decision
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Signature
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Agreed to and accepted:
By: The Graystone Company, Inc., a Delaware corporation
By: X.X. Xxxxx
Its: President
