------------------------------------------------------------------------------
SUBSCRIPTION AGREEMENT
------------------------------------------------------------------------------
_______________, 2002
Pacific InterMedia, Inc.
0000 Xxxxx Xxxx Xxxxxx
Xxxxxxxx, Xxxxxxxx 00000
Gentlemen:
In connection with your offer and my purchase of _______ shares of common
stock, as described in the Prospectus to which this Subscription Agreement is
attached, of Pacific InterMedia, Inc., a Colorado corporation, at a subscription
price of $.05 per share (for an aggregate purchase price payable by me of
$___________), I hereby represent, warrant, covenant and agree with you that at
the time of such offer and purchase and as of the date of this Subscription
Agreement:
1. I am over the age of twenty-one years.
2. I represent and warrant that I am a resident of the state in which
this offer is made insofar as I occupy a dwelling within the state and I intend
to remain within the state for an indefinite period of time. Further, if the
undersigned is not a resident of the state in which the offer is made, then the
undersigned represents and warrants that he is not a resident of any other state
or possession of the United States.
3. I have read and am familiar with the Prospectus of Pacific
InterMedia, delivery of which by you to me has preceded the closing under this
Subscription Agreement and my purchase of the shares.
The subscription made by this Subscription Agreement is subject to
acceptance by Pacific InterMedia in its sole discretion; which acceptance shall
be evidenced by Pacific InterMedia's signing and delivering to me at the address
set forth on the signature page hereof a fully-executed counterpart of this
Subscription Agreement. In the event that Pacific InterMedia shall reject my
subscription, the purchase price for the shares shall be refunded promptly to me
without interest or deduction.
1
Attached to and incorporated in that certain Subscription Agreement attached to
that certain Prospectus of Pacific InterMedia, Inc.
Very truly yours,
Individuals execute below: Corporations, partnerships,
trusts and other entities
execute below:
------------------------------------- -------------------------------------
Name (please type or print) Name (please type or print)
By:
------------------------------------- -------------------------------------
(Signature) (Signature of authorized officer,
partner or trustee)
Attest:
------------------------------------- -------------------------------------
Name (please type or print) (Signature)
------------------------------------- -------------------------------------
(Signature) (Address)
------------------------------------- -------------------------------------
(Address) (Address)
------------------------------------- -------------------------------------
(Home Telephone) (Tax Identification Number)
2
Attached to and incorporated in that certain Subscription Agreement attached to
that certain Prospectus of Pacific InterMedia, Inc.
Individuals execute below:
------------------------------------
(Office Telephone)
------------------------------------
(Social Security Number)
ACCEPTED this ___ day of ________________, 2002.
PACIFIC INTERMEDIA, INC.
By:
---------------------------------
Xx. Xxxxx X. Xxxxxx, President
ATTEST:
-------------------------------------
(Signature)
3
