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EXHIBIT 99 FORM OF SUBSCRIPTION AGREEMENT
SUBSCRIPTION AGREEMENT
Western Reserve Bancorp, Inc.
00 Xxxxxx Xxxxxx, Xxxxx 000
Xxxxxx, Xxxx 00000
Gentlemen:
The undersigned hereby subscribes for and agrees to purchase the number
of shares of common stock, no par value (the "Shares"), of WESTERN RESERVE
BANCORP, INC., an Ohio corporation (the "Company"), indicated below. The
undersigned has executed and delivered this Subscription Agreement in connection
with the Company's offering of Shares described in its Prospectus dated
________, 1998. (Such Prospectus, including any amendments and supplements
thereto, is herein called the "Prospectus.")
The undersigned agrees to purchase the Shares subscribed for herein for
the purchase price of $20.00 per share and has herewith delivered to the Company
a check made payable to MidAmerican National Bank & Trust Co., Escrow Agent in
an amount equal to the aggregate purchase price of all Shares subscribed. The
undersigned acknowledges receipt of a copy of the Prospectus.
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Number of Shares Please PRINT OR TYPE exact name(s) in
(minimum 250 shares) which undersigned desires Shares to be registered.
--------------------------- --------------------------------------------------
________Total Subscription Signature of Investor
Price (at $20.00 per share)
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Signature of Joint Investor, if any
2
SUBSTITUTE W-9
Under the penalties of perjury, I certify that: (1) the Social Security Number
or Taxpayer Identification Number given below 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
_____________________________ ________________________________
Date Signature
_____________________________ ________________________________
Area Code and Telephone No. Signature of Joint Owner, if any
_____________________________ ________________________________
Social Security or Federal Street Address
Taxpayer Identification No.
________________________________
City, State, Zip Code
Please indicate the form of ownership desired for the shares:
____ Individual ____ Corporation
____ Joint tenants with right
of survivorship ____ Partnership
____ Tenants in common ____ Custodian
____ Trust ____ Other (please describe) _________
______________________________________
TO BE COMPLETED BY THE COMPANY
Accepted as of ____________________, 1998, as to ____________________ Shares.
WESTERN RESERVE BANCORP, INC.
By:___________________________
Xxxxxx X. XxXxxx
President
