BARD HOLDING, INC. SUBSCRIPTION AGREEMENT
Exhibit 1.1
Gentlemen:
The Investor named below, by payment of the purchase price for such Common Shares, by the delivery of a check payable to BARD HOLDING, hereby subscribes for the purchase of the number of Common Shares indicated below of Bard Holding, at a purchase of $1.00 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 ($1.00/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_____________________
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D. SIGNATURES
Registered Owner: _____________________________
Co-Owner: _____________________________
Print Name of Custodian or Trustee: _____________________________
Authorized Signature: _____________________________
Date: _____________________
Signature: ___________________________________
MAIL TO:
0000 Xxxxxx Xxxxxx
Xxxxxxxxxxxx, XX 00000
(000) 000-0000
____________________________________________________________________
FOR OFFICE USE ONLY:
Date Received: ________________________________________________
Date Accepted/Rejected ________________________________________
Subscriber's Check Amount: _______________________
Check No. ___________________ Date Check ________________
Deposited ________________________________
MR #________________
____________________________________________________________________
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We have not authorized any dealer, salesperson or other person to give any information or represent anything not contained in this prospectus. You must not rely on any unauthorized information. This prospectus does not offer to sell or buy any shares in any jurisdiction where it is unlawful. The information in this prospectus is current only
as of the date of this prospectus.
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