REFERENCE 1.1
SUBSCRIPTION AGREEMENT
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0XXXXXXXX.XXX HOLDINGS INC.
SUBSCRIPTION AGREEMENT
Gentlemen:
The Investor named below, by payment of the purchase price for such Common
Shares, by the delivery of a check payable to 0XXXXXXXX.XXX HOLDINGS INC.,
hereby subscribes for the purchase of the number of Common Shares indicated
below (minimum of two hundred and fifty shares) of 0XXXXXXXX.XXX HOLDINGS INC.,
at a purchase of $0.20 per Share as set forth in the Prospectus.
By such payment, the named Investor further acknowledges receipt of the
Prospectus and the Subscription Agreement, the terms of which govern the
investment in the Common Shares being subscribed for hereby.
A. INVESTMENT: (1) Number of Shares ___________
(2) Total Contribution ($0.20/Share) $__________
Date of Investor's check ___________
B. REGISTRATION:
(3) Registered owner: _____________________________
Co-Owner: _____________________________
(4) Mailing address: _____________________________
City, State & zip: _____________________________
(5) Residence Address (if different from above):
===============================================
(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) ( ) _________________________
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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_____________________
D. SIGNATURES: By signing below, I/we represent that I/we meet the suitability
standards set forth in the Prospectus.
Registered Owner: _____________________________
Co-Owner: _____________________________
Print Name of Custodian or Trustee: _____________________________
Authorized Signature: _____________________________
Date: _____________________
Signature: ___________________________________
MAIL TO:
0XXXXXXXX.XXX HOLDINGS INC.
0000 Xxxxxxxx Xxxxxx, Xxxxx 000
Xxxxxxxxxxxx, Xxxxxxxxxxxx 00000
Telephone: 000-000-0000
Facsimile: 000-000-0000
------------------------------------------------------------------------------
FOR OFFICE USE ONLY:
Date Received: ________________________________________________
Date Accepted/Rejected ________________________________________
Subscriber's Check Amount: _______________________
Check No. ___________________ Date Check ________________
Deposited ________________________________
MR #________________
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