Exhibit 99(a)
INDIAN RIVER BANKING COMPANY
SUBSCRIPTION AGREEMENT FOR OFFERING OF SHARES OF COMMON STOCK
THE TERMS AND CONDITIONS OF THE OFFERING ARE SET FORTH IN THE ACCOMPANYING
PROSPECTUS. WE URGE YOU TO CAREFULLY READ THE PROSPECTUS IN ITS ENTIRETY BEFORE
SUBMITTING THIS SUBSCRIPTION AGREEMENT. ALL SUBSCRIPTIONS, ONCE SUBMITTED, ARE
IRREVOCABLE BY THE SUBSCRIBER.
IF YOU HAVE QUESTIONS ABOUT HOW TO COMPLETE THIS SUBSCRIPTION AGREEMENT, CONTACT
XXXX XXXX XXXXXXXX, THE SUBSCRIPTION AGENT FOR INDIAN RIVER BANKING COMPANY AT
(000) 000-0000
I. Subscription for Shares of Common Stock. The undersigned hereby irrevocably
subscribes for _______________________________ shares of common stock of Indian
River Banking Company at the purchase price of 25.00 per share.1
II. Purchase Price and Manner of Payment. The undersigned submits herewith, by
means of a check, bank draft or money order in the amount of
$_______________________ ($25.00 multiplied by the total number of shares
subscribed for in part I above), payable to "Indian River Banking Company Escrow
Account" full payment for the total number of shares subscribed for.
III. (a) Registration Instructions. This part must be completed with respect to
all shares purchased. If shares are to be registered in more than one manner,
complete as many Subscription Agreements as there are registrations, or attach
separate sheets providing all of the information required below with respect to
each registration, and indicating the number of shares subject to each
registration.
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(Name)
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(Address, including Street, City, County, State and ZIP Code)
Taxpayer identification or Social Security Number: ________________________
Manner in which securities are to be owned:
/ / Individual
/ / Tenants in Common
/ / Joint Tenants
/ / Retirement Account (Trustee signature and authorization required)
/ / Uniform Transfer to Minors
/ / Other _______________________ (for example, corporation, trust or
estate. If shares are purchased for a trust, the date of the trust
agreements and trust title must be included).
(b) Special Delivery Instructions: If certificate(s) representing the
shares subscribed for is to be delivered to an address other than as indicated
in III.(a) above, please provide the delivery address below.
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(Name)
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(Address, including Street, City, County, State and ZIP Code)
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(1) Subject to a minimum subscription of 100 shares and a maximum subscription
of 4,000, subject to our right to permit larger or smaller subscriptions.
Subject to reduction in the event that the offering is oversubscribed.
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IV. Deadline. This Subscription Agreement and payment in full of the purchase
price must be actually received by Xxxx Xxxx Xxxxxxxx, Subscription Agent for
Indian River Banking Company, 000 00xx Xxxxx, Xxxx Xxxxx, Xxxxxxx 00000, NO
LATER THAN 5:00 P.M., EASTERN TIME, ON _________, 2000, (the "Termination Date")
subject to extension or earlier termination as set forth in the prospectus.
Name(s) of Subscriber(s):
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Daytime Telephone Number: ______________________________________________________
Evening Telephone Number: ______________________________________________________
SIGNATURE(S):
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(Signature(s) of subscriber(s) exactly as name(s) appear above)
Dated: ____________________________
If signature is by trustee(s), executor(s), administrator(s), guardian(s),
attorney(s)-in-fact, agent(s), officer(s) of a corporation or another acting in
a fiduciary or representative capacity, please provide the following information
as to such person.
Name (please print): ___________________________________________________________
Capacity (Full title): _________________________________________________________
Address (including ZIP Code): __________________________________________________
Business Telephone Number (including area code): _______________________________
Taxpayer identification or Social Security Number: _____________________________
IN DETERMINING WHETHER TO ACCEPT ANY SUBSCRIPTION, IN WHOLE OR IN PART, INDIAN
RIVER MAY, IN ITS SOLE DISCRETION, TAKE INTO ACCOUNT THE ORDER IN WHICH
SUBSCRIPTIONS ARE RECEIVED, A SUBSCRIBER'S POTENTIAL TO DO BUSINESS WITH, OR TO
DIRECT CUSTOMERS TO, INDIAN RIVER BANK AND INDIAN RIVER'S DESIRE TO HAVE A BROAD
DISTRIBUTION OF STOCK OWNERSHIP, AS WELL AS LEGAL OR REGULATORY RESTRICTIONS.
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