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1.
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Investment:
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2.
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Investor
information:
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Name
(type or print)
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SSN/EIN/Taxpayer
I.D.
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E-Mail
address
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Mailing
Address
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City,
State and Zip Code
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Joint
Name (type or print)
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SSN/EIN/Taxpayer
I.D.
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E-Mail
address: ____________________
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Mailing
Address (if different from above):
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Street
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City/State
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Zip
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Business
Phone:
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( )_________________
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Home
Phone:
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( )_____________________
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3.
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Type of ownership: (You must check one
box)
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o
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Individual
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o
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Custodian
for
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o
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Tenants
in Common
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o
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Uniform
Gifts to Minors Act of the State of: __________________
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o
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Joint
Tenants with rights of Survivorship
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o
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Corporation
(Inc., LLC, LP) – Please List all officers, directors, partners, managers,
etc.:
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o
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Partnership
(Limited Partnerships use “Corporation”)
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o
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Trust
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o
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Community
Property
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o
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Other
(please explain)
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4.
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Further Representations, Warrants and
Covenants. Buyer hereby represents warrants, covenants and agrees
as follows:
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(a)
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Buyer
is at least eighteen (18) years of age with an address as set forth in
this Subscription Agreement.
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(b)
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Except
as set forth in the Prospectus and the exhibits thereto, no
representations or warranties, oral or otherwise, have been made to Buyer
by the Company or any other person, whether or not associated with the
Company or this offering. In entering into this transaction, Buyer is not
relying upon any information, other than that contained in the Prospectus
and the exhibits thereto and the results of any independent investigation
conducted by Buyer at Buyer’s sole discretion and
judgment.
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(c)
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Buyer
understands that his or her investment in the Shares is speculative and
involves a high degree of risk, and is not recommended for any person who
cannot afford a total loss of the investment. Buyer is able to bear the
economic risks of an investment in the Offering and at the present time
can afford a complete loss of such investment.
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(d)
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Buyer
is under no legal disability nor is Buyer subject to any order, which
would prevent or interfere with Buyer’s execution, delivery and
performance of this Subscription Agreement or his or her purchase of the
Shares. The Shares are being purchased solely for Buyer’s own account and
not for the account of others and for investment purposes only, and are
not being purchased with a view to or for the transfer, assignment, resale
or distribution thereof, in whole or part. Buyer has no present plans to
enter into any contract, undertaking, agreement or arrangement with
respect to the transfer, assignment, resale or distribution of any of the
Shares.
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(e)
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Buyer
has (i) adequate means of providing for his or her current financial needs
and possible personal contingencies, and no present need for liquidity of
the investment in the Shares, and (ii) a liquid net worth (that is, net
worth exclusive of a primary residence, the furniture and furnishings
thereof, and automobiles) which is sufficient to enable Buyer to hold the
Shares indefinitely.
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(f)
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If
the Buyer is acting without a Purchaser Representative, Buyer has such
knowledge and experience in financial and business matters that Buyer is
fully capable of evaluating the risks and merits of an investment in the
Offering.
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(g)
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Buyer
has been furnished with the Prospectus.
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(h)
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Buyer
understands that Buyer shall be required to bear all personal expenses
incurred in connection with his or her purchase of the Shares, including
without limitation, any fees which may be payable to any accountants,
attorneys or any other persons consulted by Buyer in connection with his
or her investment in the Offering.
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5.
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Indemnification
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6.
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Acceptance
of Subscription.
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7.
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Governing
Law.
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