Exhibit 1.1 Subscription Agreement
MEDVISION CAPITAL CORPORATION
SUBSCRIPTION AGREEMENT
Ladies and Gentlemen:
The Investor named below, by payment of the purchase price for such Common
Shares, by the delivery of a check payable to MedVision Capital Corporation,
hereby subscribes for the purchase of the number of Common Shares indicated
below of MedVision Capital Corporation, at a purchase price of $0.50 per Share
as set forth in the Prospectus.
By such payment, the named Investor further acknowledges receipt of the
Prospectus and the Subscription Agreement, the terms of which govern the
investment in the Common Shares being subscribed for hereby.
A. INVESTMENT: (1) Number of Shares _______________________________
(2) Total Contribution ($0.50/Share) $______________
Date of Investor's check ________________
B. REGISTRATION:
(3) Registered owner: ______________________________
Co-Owner: _______________________________
(4) Mailing address: _______________________________
City, State & zip: ______________________
(5) Residence Address (if different from above):
============================================
(6) Birth Date: ______/______/______
(7) Employee or Affiliate: Yes ______ No ______
(8) Social Security: #: ______/______/______
U.S. Citizen [ ] Other [ ]
Co-Owner Social Security:
#: ______/______/______
U.S. Citizen [ ] Other [ ]
Corporate or Custodial:
Taxpayer ID #: ______/______/______
U.S. Citizen [ ] Other [ ]
(9) Telephone (H) ( ) ______________________
C. OWNERSHIP [ ] Individual Ownership [ ] XXX or Xxxxx
[ ] Joint Tenants with Rights of Survivorship
[ ] Trust/Date Trust Established_______________
[ ] Pension/Trust (S.E.P.)
[ ] Tenants in Common [ ] Tenants by the
Entirety
[ ] Corporate Ownership [ ] Partnership
[ ] Other_____________________
D. SIGNATURES:
Registered Owner: _____________________________
Co-Owner: _____________________________
Print Name of Custodian or Trustee: _____________________________
Authorized Signature: _____________________________
Date: _____________________
Signature: ___________________________________
MAIL TO:
MedVision Capital Corporation
0000 Xxxxxxxx Xxxxxx, #000
Xxxxxxxxxxxx, Xxxxxxxxxxxx 00000-0000
Telephone / Fax: (000) 000-0000
____________________________________________________________________
FOR OFFICE USE ONLY:
Date Received: ________________________________________________
Date Accepted/Rejected ________________________________________
Subscriber's Check Amount: _______________________
Check No. ___________________ Date Check ________________
Deposited ________________________________
MR #________________
____________________________________________________________________
