PLANET BEACH FRANCHISING CORPORATION SUBSCRIPTION AGREEMENT
Gentlemen:
The
Investor named below, by payment of the purchase price for shares of Common
Stock of Planet Beach Franchising Corporation (the “Company”), by the delivery
of a check payable to the Company, hereby subscribes for the purchase of the
number of shares of Common Stock of the Company indicated below, at a purchase
of $0.50 per share as set forth in the Prospectus.
By
such
payment, the named Investor further acknowledges receipt of the Prospectus
and
this Subscription Agreement, the terms of which govern the investment in the
shares of Common Stock of the Company being subscribed for hereby.
The
named
Investor further confirms that either Xxxxxxx Xxxxx, Xxxxxxx Xxxx or Xxxxx
Xxxxx
(collectively, the “Company Officers”) solicited him/her/it to purchase the
shares of Common Stock of the Company and that no other person participated
in
such solicitation other than the Company Officers.
A.
INVESTMENT:
| (1) |
Number
of Shares
___________________________
|
| (2) |
Total
Contribution ($0.50/Share)
$________
|
Date
of
Investor's check __________
B.
REGISTRATION:
| (3) |
Registered
owner: ________________________
|
Co-Owner
(if applicable): ___________________
| (4) |
Mailing
address: _________________________
|
City,
State & zip: _________________________
| (5) |
Residence
Address (if different from above):
Address:
___________________________________
City,
State and Zip:
___________________________
|
| (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) ( )
_____________________
|
| (10) |
Facsimile:
____________________________
|
| (11) |
E-mail:
_______________________________
|
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:
Attn:
Xxxxxxx Xxxx - Subscription Agreement
0000
Xxxxxxxxx Xxxx
Xxxxxxx,
Xxxxxxxxx 00000
Tel
No:
(000) 000-0000
____________________________________________________________________
FOR
OFFICE USE ONLY:
Date
Received: ________________________________________________
Date
Accepted/Rejected: ________________________________________
Subscriber's
Check Amount: _______________________
Check
No.
___________________ Date Check ________________
Deposited
________________________________
3
