SUBSCRIPTION AGREEMENT
Exhibit 10.4 – Offering Subscription Agreement
(the “Company”)
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3577 – 000 Xxxx Xxxxxxx Xxxxxx
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Xxxxxxxxx, XX X0X 0X0
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Tel: (000) 000-0000
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A.
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Instructions.
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Each person considering subscribing for common shares of the Company should review the following instructions:
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Subscription Agreement: Please complete, execute and deliver to the Company the enclosed copy of the Subscription Agreement. The Company will review the materials and, if the subscription is accepted, the Company will execute the Subscription Agreement and return one copy of the materials to you for your records.
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The Company shall have the right to accept or reject any subscription, in whole or in part.
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An acknowledgment of the acceptance of your subscription will be returned to you promptly after acceptance.
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Payment: Payment for the amount of the Shares subscribed for (the "Payment") shall be made at the time of delivery of the properly executed Subscription Agreement, or at such later date as the Company may specify by written notice to subscribers (unless such date is deferred in the sole discretion of the Company), by check, bank draft or wire transfer of funds immediately available to the Company at the address set forth below or to an account specified by the Company. The date upon which the transaction contemplated hereby shall become effective (the "Closing") will occur on such date or within such period as may be specified at the discretion of the Company with written notice to the Subscriber. There is no minimum aggregate amount of Shares which must be sold as a condition precedent to the Closing, and the Company may provide for one or more Closings while continuing to offer the Shares that constitute the unsold portion of the Offering.
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B.
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Communications.
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All originally signed documents should be forwarded to:
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3577 – 000 Xxxx Xxxxxxx Xxxxxx
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Xxxxxxxxx, XX X0X 0X0
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Tel: (000) 000-0000
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THE PURCHASE OF SHARES OF DANE EXPLORATION INC. INVOLVES A HIGH DEGREE OF RISK AND SHOULD BE CONSIDERED ONLY BY PERSONS WHO CAN BEAR THE RISK OF THE LOSS OF THEIR ENTIRE INVESTMENT.
EVERY POTENTIAL INVESTOR PRIOR TO ANY INVESTMENT OR PURCHASE OF DANE EXPLORATION INC.’S SHARES SHOULD READ THE PROSPECTUS RELATING TO THIS OFFERING.
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3577 – 000 Xxxx Xxxxxxx Xxxxxx
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Xxxxxxxxx, XX X0X 0X0
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Tel: (000) 000-0000
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SUBSCRIPTION AGREEMENT SIGNATURE PAGE
The undersigned (the "Subscriber") hereby subscribes for that number of shares (the “Shares”) of the Company set forth below, upon and subject to the terms and conditions set forth in the Company’s final prospectus filed on Form 424B and dated September 20, 2011 (the “Prospectus”).
The Company acknowledges that the Subscriber has a two day cancellation right and can cancel this Subscription Agreement by sending notice to the Company by midnight on the 2nd business day after the Subscriber signs this Subscription Agreement.
The Subscriber acknowledges, represents and warrants as of the date of this Subscription Agreement that:
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1.
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no person has made to the Subscriber any written or oral representations:
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(a) that any person will resell or repurchase the Shares,
(b) that any person will refund the purchase price of the Shares, or
(c) as to the future price or value of the Shares;
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2.
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the Company has provided to the Subscriber a copy of the Prospectus and has made available a copy of the Company’s Registration Statement on Form S-1 filed on May 31, 2012;
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3.
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the representations, warranties and acknowledgements of the Subscriber contained in this Section will survive the closing of this Agreement;
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4.
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subsequent to the two day cancellation right provided by the Company which allows the Subscriber to cancel this Subscription Agreement by sending notice to the Company by midnight on the 2nd business day after the Subscriber signs this Subscription Agreement, that the Company has the right to use any, or all, of the Subscriber's Payment for working capital purposes of the Company, whether or not such expenditures are prior to the issuance of shares to the Subscriber.
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| Total Number of Shares to be Acquired: | _______________ shares | ||
| Amount to be paid (at a price of $0.02 USD per Share): | US$_________________ |
IN WITNESS WHEREOF, the undersigned has executed this Subscription Agreement this ___ day of ____________, 2012.
Dane Exploration Inc. - Shares Purchase Subscription
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| NAME: | (PRINT) as it should appear on the Certificate: | ||
| ADDRESS: | |||
If Joint Ownership, check one (all parties must sign above):
___ Joint Tenants with Right of Survivorship
___ Tenants in Common
___ Community Property
If Fiduciary or a Business or an Organization, check one:
___ Trust
___ Estate
___ Power of Attorney
Name and Type of Business Organization:
__________________________________________________
Dane Exploration Inc. - Shares Purchase Subscription
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Identification Authentication REQUIRED [Attach photocopy of ID]
Below is my (check one)
| I.D. Number: | |||
| ___ Passport: | #____________________ | ||
| ___ Drivers License: | #____________________ | ||
| ___ Government ID: | #____________________ | ||
| ___ Social Security: | #____________________ | ||
| ___ Tax ID: | #____________________ | ||
| ___ Other ____________: | #____________________ |
Signature: __________________________________________
Print Name: __________________________________________
ACCEPTANCE OF SUBSCRIPTION
The foregoing Subscription is hereby accepted for and on behalf of DANE EXPLORATION INC. this ______ day of ____________________, 20____.
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By:
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| Xxxxx Xxxxxxxx, President and CEO |
Dane Exploration Inc. - Shares Purchase Subscription
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