SUBSCRIPTION AGREEMENT
Exhibit
4.1
0000
Xxxxxx Xxxxx
Xxxxxxxxx,
Xxxxxx 00000
The
undersigned has received the prospectus dated __________, 2007 (“Prospectus”),
and hereby subscribes for _____________ shares of $.001 par value common
stock
of BLS Media, Inc., a Nevada corporation (“Company”), for a subscription price
of $0.10 per share (“Offered Shares”). The undersigned hereby agrees that this
subscription shall be irrevocable and shall survive the death or disability
of
the undersigned. Payment of the purchase price for the Offered Shares is
due
upon subscription.
The
undersigned acknowledges that (i) the Company has the right to accept or
reject
this subscription in whole or in part, (ii) this subscription shall be
deemed to
be accepted by the Company only when the Company signs this Subscription
Agreement; and (iii) the undersigned has relied only on that information
specified in the Prospectus.
Number
of
Offered Shares: _________________. Subscription Amount: ___________ (number
of
Offered Shares multiplied by $0.10)
Make
check payable to: “BLS
Media, Inc.”
Please
print name(s) or title, residence address, and SSN or Tax ID for which
the
Offered Shares are to be registered. Please notify the Company in writing
if
your address changes before you either receive your shares or are notified
that
your subscription has not been accepted.
Name
Street
City State Zip
Code
SSN
or Tax ID No. (For joint ownership, both parties must provide a Social
Security
Number or similar tax identification)
Indicate
type of ownership:
|
o
Individual
Ownership
|
o
Joint
Tenants
with Right of Survivorship
|
|
|
o
Community
Property
|
o
Tenants
in
Common
|
|
|
o
Tenants
by the
Entirety
|
o
Corporate
Ownership
|
|
|
o
Partnership
Ownership
|
o
Custodian
for a
Minor
|
|
|
o
Trust
(see
below)
|
o
XXX
or Pension
Plan
|
Date
Trust Established:
Name
of
Trustee or other Administrator:
1
Each
subscriber represents that:
| (a) |
The
information contained herein is complete and accurate and may be
relied
upon, and
|
| (b) |
The
undersigned will notify the Company immediately of any material
change in
any such information occurring prior to the acceptance of the
undersigned’s subscription, including any changes in address or other
contact information.
|
IN
WITNESS WHEREOF, the undersigned has executed this Subscription Agreement
as of
this ______ day of ____________ 2007.
FOR
INDIVIDUALS:
Print
Name
Signature
NAME
AND SIGNATURE OF JOINT TENANT OR TENANT IN COMMON
Print
Name
Signature
FOR
TRUSTS, CORPORATIONS, PARTNERSHIPS
Print
Name of Entity
By:
Print
name and capacity (Trustee, President or General Partner) of person making
investment decision
Signature
Agreed
to
and accepted:
|
By:
|
|
|
a
Nevada corporation
|
|
|
By:
|
___________________________
|
|
Xxxxxxxx
Xxxxxx
|
|
|
Its:
|
President
|
2
