MAXIM MORTGAGE CORPORATION SUBSCRIPTION AGREEMENT
REFERENCE 4.1 SUBSCRIPTION AGREEMENT
MAXIM MORTGAGE
CORPORATION
SUBSCRIPTION
AGREEMENT
Gentlemen:
The Investor named below, by payment of the purchase price for common shares, by the delivery of a check payable to MAXIM MORTGAGE CORPORATION subscribes for the purchase of the number of common shares indicated below of MAXIM MORTGAGE CORPORATION at a purchase of $0.05 per Share as set forth in the prospectus.
By making the 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.
A. INVESTMENT:
(1) Number of shares __________
(2) Total Contribution
($0.05/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) ( )
______________________
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:
Registered
Owner:_____________________________
Co-Owner:____________________________________
Print Name of Custodian or
Trustee:______________________________________
Authorized
Signature:___________________________
Date:_____________________
Signature_____________________________________
MAIL TO: MAXIM MORTGAGE
CORPORATION
00000 Xxxxxx
Xxxxx Xxxxx
Xxxxxxxxxx, Xxxxxxx
00000
Telephone (000)
000-0000
OFFICE USE ONLY:
Date
Received:___________
Date
accepted/Rejected_________________________________________
Subscriber's Check
Amount:_______________________
Check
No.___________________
Date Check
________________ Deposited________________________________
