REFERENCE 1.1
SUBSCRIPTION AGREEMENT
XXXXXXXXXX.XX, INC.
SUBSCRIPTION AGREEMENT
Gentlemen:
The Investor named below, by payment of the purchase price for such Common
Shares, by the delivery of a check payable to XXXXXXXXXX.XX, INC., hereby
subscribes for the purchase of the number of Common Shares indicated below
(minimum of fifty thousand shares) of XXXXXXXXXX.XX, INC., at a purchase of
$0.10 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 ($0.10/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 [ ]
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(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: By signing below, I/we represent that I/we meet the suitability
standards set forth in the Prospectus.
Registered Owner: _____________________________
Co-Owner: _____________________________
Print Name of Custodian or Trustee: _____________________________
Authorized Signature: _____________________________
Date: _____________________
Signature: ___________________________________
MAIL TO:
Xxxxxxxxxx.xx, Inc.
0000 Xxxxxx Xxxx, Xxxxx 000
Xxx Xxxxx, Xxxxxxxxxx 00000
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FOR OFFICE USE ONLY:
Date Received: ________________________________________________
Date Accepted/Rejected ________________________________________
Subscriber's Check Amount: _______________________
Check No. ___________________ Date Check ________________
Deposited ________________________________
MR #________________
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