SUBSCRIPTION AGREEMENT ALLIANCE PETROLEUM CORPORATION
Exhibit 10.4
ALLIANCE PETROLEUM CORPORATION
The undersigned (the “Subscriber”) hereby irrevocably subscribes for that number of shares of common stock, par value $0.001 per share (the “Shares”), of Alliance Petroleum Corporation, a Nevada corporation (the “Company”), set forth below, upon and subject to the terms and conditions set forth in the Company’s Prospectus dated ________________, 2011 in the United States Securities and Exchange Commission Registration Statement on Form S-1, to which this Subscription Agreement is attached.
This Subscription Agreement is for the purchase of shares of common stock of the Company from the Company’s offering of 500,000 shares in the Company’s Prospectus, at an offering price of $0.20 per share. This Subscription Agreement is not for the purchase shares of common stock, also at an offering price of $0.20 per share, from the offering of 4,050,000 shares by certain selling stockholders of the Company, also being made under the Prospectus.
Total number of shares subscribed for at US $0.20 per share: ________________ shares.
Amount paid with this Subscription Agreement at a price of US $0.20 per Share: US $__________________.
This Subscription Agreement constitutes the entire agreement among the parties hereto with respect to the subject matter hereof and may be amended only by a writing executed by all parties.
IN WITNESS WHEREOF, the undersigned has executed this Subscription Agreement this ___ day of _____________, 2011.
Name of Entity (for purchasers which are entities only): ________________________________
Signature: __________________________________________
Print Name: ________________________________________
Print Title (for purchasers which are entities only): _________________________________________
Address: ___________________________________________
__________________________________________
Telephone No.: _____________________________________
E-mail Address: ____________________________________
Subscriber’s US Social Security Number or
identification number of home jurisdiction: ___________________________
Signature of Co-owners, if applicable: ___________________________________
Name as it should appear on the Certificate: _______________________________
If Joint Ownership, check one (all parties must sign above):
[ ] Joint Tenants with Right of Survivorship
[ ] Tenants in Common
[ ] Community Property
If Fiduciary or Business Entity check one:
[ ] Trust
Authorized Person _________________________ Capacity_____________________
[ ] Estate
Authorized Person _________________________ Capacity_____________________
[ ] Corporation
Authorized Person _________________________ Capacity_____________________
[ ] Limited Liability Company
Authorized Person _________________________ Capacity_____________________
[ ] Partnership
Authorized Person _________________________ Capacity_____________________
[ ] Other ____________________ (Describe)
Authorized Person _________________________ Capacity_____________________
PAYMENT BY CHECK OR MONEY ORDER INSTRUCTIONS
If Subscriber wishes to pay the purchase price of his or her Shares by check, all checks or money orders shall be made payable to: Alliance Petroleum Corporation, 000 Xxxxx Xxxxx Xxxxxx, Xxxxxx Xxxx Nevada, telephone (000) 000-0000.
WIRE TRANSFER INSTRUCTIONS
If Subscriber wishes to wire transfer the purchase price of his Shares, he or she shall wire transfer immediately available funds in the amount of the purchase price subscribed for hereunder, as follows:
Bank:
________________________
Account Name:
________________________
Account No.:
________________________
ABA Routing No.:
________________________
SWIFT code:
________________________
Bank Contact:
________________________
ACCEPTANCE OF SUBSCRIPTION
The foregoing Subscription is hereby accepted for and on behalf of Alliance Petroleum Corporation this
_____day of _____________, 2011.
ALLIANCE PETROLEUM CORPORATION
By: _______________________________________
Name: Xxxxxxx Xxxx
Title: President and Chief Executive Officer
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