Exhibit 10.4
SUBSCRIPTION AGREEMENT
Corporate Road Xxxx.Xxx Inc.
00 Xxxxxxx Xxxxx
Xxxxx 000
Xxxxxxx, Xxx Xxxx 00000
Gentlemen:
The undersigned ("Subscriber") desires to become a shareholder in Corporate
Road Xxxx.Xxx Inc., a New York corporation ("Company"), and hereby subscribes
for __________ shares of the Company's common stock, $0.0001 par value
(collectively, "Shares"), which are more fully described in the Company's
prospectus dated [_______], 2003 ("Prospectus"), upon the terms and conditions
set forth below.
1. The Subscriber hereby delivers a check drawn to the order of the Company
in the amount of $__________, which the undersigned agrees to contribute to the
capital of the Company, representing the aggregate purchase price of the Shares
subscribed for above at the subscription price of $1.00 per share. The
Undersigned acknowledges that this Agreement is contingent in whole or in part
on the Company's acceptance of this Agreement.
2. The Undersigned acknowledges and represents as follows:
(a) That the Undersigned has received the Prospectus;
(b) That the Undersigned is able to bear the economic risk of the
investment in the Shares;
(c) That the Undersigned has such knowledge and experience in
financial and business matters so as to be capable of evaluating the merits and
risks of the prospective investment in the Shares and has the net worth to
undertake such risks; and
(d) That the Undersigned believes that the investment in the Shares is
suitable based upon the Undersigned's investment objectives and financial needs,
and the Undersigned has adequate means for providing for current financial needs
and personal contingencies and has no need for liquidity of investment with
respect to the Share if a market does not develop.
3. The Undersigned represents and warrants that he is a bona fide resident
of, and is domiciled in, the State of ___________ and that the Shares are being
purchased solely for the beneficial interest of the Undersigned.
4. The Undersigned is informed of the significance to you of the foregoing
representations and they are made with the intention that you will rely upon
them.
5. The Shares are to be owned and should be registered as follows (please
print):
Names _________________________________________________________________
________________________________________________________________________________
( ) (a) A single person
( ) (b) Husband and wife, as tenants in the entirety
( ) (c) Joint Tenants
( ) (d) Tenants in Common
( ) (e) A married (man)(woman) as (his)(her) separate property
( ) (f) Corporation
( ) (g) Trust:
(1) Trustee(s) ____________________________________________________________
(2) Trust date ____________________________________________________________
(3) Name of Trust _________________________________________________________
(4) For the benefit of ____________________________________________________
_______________________________________________________________________
( ) (h) Custodian:
A custodian for _______________________________________________________
under the Uniform Gift to Minors Act of the State of
_______________________________________________________________________
( ) (i) Other _________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(please explain)
In order to facilitate processing of your subscription, please be sure you have
completed each of the following:
A. Check made out to "Corporate Road Xxxx.Xxx Inc."
B. Enter number of Shares and total cash contribution on this
Subscription Agreement, and make sure you check the correct form of
ownership in Section 5 above.
C. In Section 3 above, enter the state in which you are a legal resident.
D. If the securities are to be owned in the name of more than one person,
each co-owner must sign.
I declare that the foregoing is true and correct.
Dated: ___________________, 200__.
X___________________________________________
Signature of "Subscriber" (see Note D above)
Current residence address of Subscriber: _______________________________________
_____________________________________________ Zip Code ___________________
Mailing address (if different) _________________________________________________
Social Security or Taxpayer I.D. No. ___________________________________________
Telephone number: (______) _____________________________________________________
X ___________________________________________
Signature of "Co-Subscriber" (see Note D above)
Current residence address of Co-Subscriber: ____________________________________
_____________________________________________ Zip Code ___________________
Mailing address (if different) _________________________________________________
Social Security or Taxpayer I.D. No. ___________________________________________
Telephone number: (______) _____________________________________________________
FOR COMPANY USE ONLY:
Fund and subscription accepted:
CORPORATE ROAD XXXX.XXX INC.
By: /s/ Xxxxx Xxxxxxx
---------------------------------
Xxxxx Xxxxxxx, President
Date: ______________________________
