Exhibit 4.1
Form of Subscription Agreement
SUBSCRIPTION FORM
To: XXXXXXXX.XXX
The undersigned hereby acknowledges receipt of the Prospectus, dated
___________, 1999, of Xxxxxxxx.xxx (the "Company") and subscribes for the
following number of Shares of the Company upon the terms and conditions set
forth therein:
Number of Shares: All subscriptions are subject to
---------------- acceptance by the Company, to
Price Per Share: $ availability, and to certain other
---------------- conditions, and any subscription
Payment Enclosed: $ may be declined in whole or in
---------------- part by return of the subscription
Make checks payable to "Xxxxxxxx.xxx" monies without interest.
Date:_________________, 1999 Accepted by Company:
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Authorized officer
------------------------------------- for _________________ Shares
(Signature(s) of Subcriber(s)
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Social Security or Tax I.D.
The certificates for such stock are to Check one if more than one owner:
be issued as follows:
_
|_| Joint tenants WRS
------------------------------------- _
Name(s) |_| Tenants in Common
------------------------------------- _
|_| Custodian under UGMA
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Address Other:_____________________
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