Amount of Investment. Purchaser understands that the Tendered Crypto will not be held by the Company, but instead will converted into U.S. dollars by a reputable third party chosen by the Company, with the net proceeds (denominated in U.S. dollars, and after subtracting fees paid to the third party) paid to the Company. The purchase price of the LLC Interest (and, for purposes of the LLC Agreement, Purchaser’s “Capital Contribution”) will be equal to the amount of such net proceeds paid to the Company, denominated in U.S. dollars, and not the nominal value of the Tendered Crypto.
Amount of Investment. Please indicate the amount of your proposed investment: __________________________________________________
Amount of Investment. Number of Units (minimum 3 Units per Investor):______________ Corresponding dollar amount ($10,000 multiplied by number of Units): $_______________ Date of Formation or incorporation: ____________ State of Formation: _____________________ Describe the business of the Entity: _________________________________________________________________________________ _____________________________________________________________________________________________________________ List the names and positions of the executive officers, managing members, partners or trustees authorized to act with respect to investments by the Entity generally and specify who has the authority to act with respect to this investment. Name Position Authority for this investment (yes or no)
Amount of Investment. Purchaser, having received and read in its entirety the Company’s Confidential Private Placement Memorandum dated February 1, 2012, and all supplements and amendments thereof if any (the “PPM”), hereby offers to purchase the number of Units set forth on page 3 for a total purchase price of such number of Units times the Offering Price (the “Subscription Amount”). (For more information regarding the Units, please refer to the PPM.)
Amount of Investment. The amount of the investment is $4,000,000 (four million dollars).
Amount of Investment. Number of Units (minimum of 3 Units per Investor) :______________ Corresponding dollar amount ($10,000 multiplied by number of Units): $_______________ Accredited Investor Status For Individuals. (INVESTORS THAT ARE CORPORATIONS, LIMITED LIABILITY COMPANIES, PARTNERSHIPS, REVOCABLE TRUSTS, IRREVOCABLE TRUSTS, EMPLOYEE BENEFIT PLAN TRUSTS AND INDIVIDUAL RETIREMENT ACCOUNTS SHOULD IGNORE THE FOLLOWING QUESTIONS AND PROCEED TO THE ENTITY SIGNATURE PAGE).
Amount of Investment. Number of Units (minimum of 1 Unit per Investor) : ________________________________ Corresponding dollar amount ($25,000 multiplied by number of Units): $ ________________________________ Accredited Investor Status For Individuals. (INVESTORS THAT ARE CORPORATIONS, LIMITED LIABILITY COMPANIES, PARTNERSHIPS, REVOCABLE TRUSTS, IRREVOCABLE TRUSTS, EMPLOYEE BENEFIT PLAN TRUSTS AND INDIVIDUAL RETIREMENT ACCOUNTS SHOULD IGNORE THE FOLLOWING QUESTIONS AND PROCEED TO THE ENTITY SIGNATURE PAGE). I am an accredited investor within the meaning of Section 2(15) of the Securities Act and Rule 501 promulgated thereunder because (check any boxes that apply): My individual annual income during each of the two most recent years exceeded $200,000 and I expect my annual income during the current year will exceed $200,000. If I am married, my joint annual income with my spouse during each of the two most recent years exceeded $300,000 and I expect my joint annual income with my spouse during the current year will exceed $300,000. My individual or joint (together with my spouse) net worth (including my home, home furnishings and automobiles) exceeds $1,000,000. The aggregate value of my assets is approximately $___________. My aggregate liabilities are approximately $___________. My current and expected income is: YEAR INCOME 2005 (Estimated) $ 2004 (Actual) $ 2003 (Actual) $ I hereby confirm the information set forth above is true and correct in all respects as of the date hereof and will be on the date of the purchase of Units. ALL INVESTORS MUST SIGN AND The foregoing subscription is accepted and the PRINT NAME BELOW Company hereby agrees to be bound by its terms. Signature: PUDA COAL, INC. Print Name: By: Date: Name: Signature: Title: Print Name: Date: Date: SIGNATURE PAGE FOR ENTITY INVESTORS - COMPLETE ALL INFORMATION Name of Entity: Address of Principal Office: Telephone: Fax: Taxpayer Identification Number: Check type of Entity: Employee Benefit Limited General Individual Plan Trust Partnership Partnership Retirement Account Limited Liability Revocable Corporation Other Company Trust (please indicate) Irrevocable Trust (If the Investor is an Irrevocable Trust, a supplemental questionnaire must be completed by the person directing the decision for the trust to determine by accredited investor status. Please contact Kxxxxxx Securities for a copy of such supplemental questionnaire.) S
Amount of Investment. Number of Units (minimum 1 Unit per Investor): Corresponding dollar amount ($25,000 multiplied by number of Units): $ Date of Formation or incorporation: State of Formation: Describe the business of the Entity: List the names and positions of the executive officers, managing members, partners or trustees authorized to act with respect to investments by the Entity generally and specify who has the authority to act with respect to this investment. Authority for this investment Name Position (yes or no) Accredited Investor Status for Entities.
Amount of Investment. $______ Number of Shares: __________ Full Name of Investor: ________________________________________________ Permanent Address of Investor: ______________________________________________________________________________ ______________________________________________________________________________ Authorized Signatory: ___________________________
Amount of Investment. $--------------------- INDIVIDUAL INVESTOR: ---------------------- Name: PARTNERSHIP, CORPORATION, TRUST, CUSTODIAL ACCOUNT, OTHER INVESTOR --------------------------- (Print Name of Entity) By: __________________ Name: Title: Address: Taxpayer Identification Number:_____________ ACCEPTANCE OF SUBSCRIPTION (to be filed out only by the Company) The Company hereby accepts the above application for subscription for Units on behalf of the Company. SAFETEK INTERNATIONAL, INC. Dated:_________ ___, 2005 By:______________________________ Name: Shay Goldstein Title: Chief Execxxxxx Xxxxxxx, Chairman, and Secretary SAFETEK INTERNATIONAL, INC. INVESTOR QUESTIONNAIRE
