SUBSCRIPTION AGREEMENT
Exhibit 99.1
XXXX, INC. – COMMON STOCK
Investment
I desire to purchase ___________________________ shares of Xxxx, Inc at $0.05 per share for a total of $ _____________________________
Make Checks Payable to:
Escrow Specialists, Xxxx, Inc., Escrow Account
Subscriber Information: Please clearly print name(s) in which Shares are to be acquired. All correspondence will go to the Investor Residence Address
Investor 1 (First, Middle I., Last):
_________________________________________________________________________________________________________________________
Investor 2 (First, Middle I. Last):
_________________________________________________________________________________________________________________________
Registration for the Investment (how the investment should be titled):
_________________________________________________________________________________________________________________________
Investor Residence Address 1:
Check one of the following:
__________________________________________________________________
[ ]
U.S. Citizen
Investor Residence Address 2:
[ ]
Resident Alien
__________________________________________________________________
City,
State
ZIP Code
[ ]
Foreign Resident; Country ________
__________________________________________________________________
[ ]
U.S. Citizen residing outside the U.S.
Enter the taxpayer identification number. For most individual taxpayers, it is their Social Security Number. Note: If the purchase is in more than one
name, the number should be that of the first person listed. For IRAs, Keoghs, and qualified plans, enter both the Social Security Number and the
Taxpayer Identification Number for the plan.
Social Security Number
Taxpayer Identification Number (if applicable)
__________________________________________
_______________________________________
Form of Ownership (Individual, XXX, Trust, UGMA, Pension Plan, etc.)
_________________________________________________________________________________________________________________________
Subscriber Signature: The undersigned has the authority to enter into this subscription agreement on behalf of the person(s) or entity registered above.
Authorized Signature of Investor 1
________________________________________
Date:_____________________________________
Authorized Signature of Investor 2
________________________________________
Date:_____________________________________
Company’s Acceptance (To be completed only by an authorized representative of the Company.)
The foregoing subscription is accepted this ____________ day of ________________, _____
___________________________________
Authorized Representative of the Company
