Common use of Investor Information Clause in Contracts

Investor Information. (The information below should be consistent with the form of ownership selected below.) Name (please print):__________________________________________________________ If entity named above, By:__________________________________________________ Its:_________________________________________________ Social Security or Taxpayer I.D. Number:___________________________________ Business Address (including zip code):______________________________________ ________________________________________________________________________________ Business Phone:________________________________________________________________ Residence Address (including zip code):_____________________________________ ________________________________________________________________________________ Residence Phone:_______________________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th day of May, 2004, at Scranton, PA. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004.

Appears in 2 contracts

Samples: Procera Networks Inc, Procera Networks Inc

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Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit A, included herewith.) Name (please print):____________________________________________________________________________ If entity named above, By:: _______________________________________________________________________ Its:: _______________________________________________________________________ Social Security or Taxpayer I.D. Number:___________________________________ Business Address (including zip code):______________________________________ ___________________Business Address (including zip code): _____________________________________________________________ Business Phone:_______________________________________________________________________________ Residence Address (including zip code):_____________________________________________________________ Email Address:________________________________________________________________________________ Residence Phone:______________________________________________________________________________ All communications to be sent to: :__________________________________________________________________ _______ Business or ________ Residence Address ________ Email ______________________________________ 7 Subscription Agreement Participant’s Initials Pacific Energy Development Corp. Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investorinves­tor's domicile and his or her particular personal circumstances. _____ ___INDIVIDUAL OWNERSHIP (one signature required) _____ ___JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ ___COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ ___TENANTS IN COMMON (both or all parties must sign) _____ ___GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ ___LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ ___LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ ___CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ ___TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) 8 Subscription Agreement Participant’s Initials Pacific Energy Development Corp. Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th _______ day of May_____, 2004, at Scranton, PA2012. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004.PARTICIPANT

Appears in 2 contracts

Samples: Subscription Agreement (Pedevco Corp), Subscription Agreement (Pedevco Corp)

Investor Information. (The information below should be consistent with the form of ownership selected below.) Name (please print):____________________________________________________________ If entity named above, By:_____________________________________________________ Its:____________________________________________________ Social Security or Taxpayer I.D. Number:________________________________________ Business Address (including zip code):__________________________________________ ________________________________________________________________________________ Business Phone:_________________________________________________________________ Residence Address (including zip code):_________________________________________ ________________________________________________________________________________ Residence Phone:________________________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th ____ day of Mayof, 20042003, at Scranton, PAat______________,_______________. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner [See Schedule 3] ------------------------------ Participant The Company has accepted this subscription this 24th 5th day of May 2004December, 2003.

Appears in 1 contract

Samples: Subscription Agreement (Procera Networks Inc)

Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit B, included herewith.) Name (please print):): _________________________________________________________________________ If entity named above, By:: ____________________________________________________________________ Its:: ____________________________________________________________________ Social Security or Taxpayer I.D. Number:: __________________________________________________________ Business Address (including zip code):): ___________________________________________________________ _________________________________________________________________________________________ Business Phone:: ____________________________________________________________________________ Residence Address (including zip code):): __________________________________________________________ _________________________________________________________________________________________ Email Address: _____________________________________________________________________________ Residence Phone:: ___________________________________________________________________________ All communications to be sent to: _______ Business or ________ Residence Address ________ Email Subscription Agreement Participant’s Initials 22 Generation Hemp, Inc. Please indicate below the form in which you will hold title to your interest in the SharesUnits. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND/OR WARRANTS AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTIONSUBSCRIPTION OR APPLICABLE LAW, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the SharesUnits, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _______ INDIVIDUAL OWNERSHIP (one signature required) _______ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _______ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _______ TENANTS IN COMMON (both or all parties must sign) _______ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _______ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _______ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _______ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _______ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subscription Agreement Participant’s Initials 23 Generation Hemp, Inc. Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her her/its subscription for participation in the Shares purchase of Securities of the Company, this 24th _______ day of May_____, 2004, at Scranton, PA2020. LINDEN GROWTH PARTNERS PARTICIPANT (Signature By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) TitleIf Entity, Entity Name: General Partner ____________________ Its: The Company has accepted this subscription this 24th ____ day of May 2004__________ 2020 “COMPANY” GENERATION HEMP, INC., a Colorado corporation By: Xxxx X. Xxxxx Chairman and CEO Address for notice: Generation Hemp, Inc. X.X. Xxx 000000 Xxxxxx, Xxxxx 00000 Attn: xxxxxx@xxxxxxxxxx.xxx Subscription Agreement Participant’s Initials 24 Generation Hemp, Inc. Exhibit A Form of Warrant Subscription Agreement Participant’s Initials 25 Generation Hemp, Inc. Exhibit B CERTIFICATE OF ACCREDITED INVESTOR STATUS Except as may be indicated by the undersigned below, the undersigned is an “accredited investor,” as that term is defined in Regulation D under the Securities Act of 1933, as amended (the “Securities Act”). The undersigned has initialed the box below indicating the basis on which he is representing his status as an “accredited investor”: ______ a bank as defined in Section 3(a)(2) of the Securities Act, or any savings and loan association or other institution as defined in Section 3(a)(5)(A) of the Securities Act whether acting in its individual or fiduciary capacity; a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Securities Exchange Act”); an insurance company as defined in Section 2(13) of the Securities Act; an investment company registered under the Investment Company Act of 1940 or a business development company as defined in Section 2(a)(48) of that Act; a small business investment company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958; a plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, and such plan has total assets in excess of $5,000,000; an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, if the investment decision is made by a plan fiduciary, as defined in Section 3(21) of such Act, which is either a bank, savings and loan association, insurance company, or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are “accredited investors”; ____ a private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940; ____ an organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000; ____ a natural person whose individual net worth, or joint net worth with the undersigned’s spouse, at the time of this purchase exceeds $1,000,000. For purposes of this item, "net worth" means the excess of total assets at fair market value (including personal and real property, but excluding the estimated fair market value of a person's primary home) over total liabilities. Total liabilities excludes any mortgage on the primary home in an amount of up to the home's estimated fair market value as long as the mortgage was incurred more than 60 days before the Securities are purchased, but includes (i) any mortgage amount in excess of the home's fair market value and (ii) any mortgage amount that was borrowed during the 60-day period before the closing date for the sale of Securities for the purpose of investing in the Securities; ____ a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with the undersigned’s spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year; ____ a trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a person who has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of the prospective investment; ____ an entity in which all of the equity holders are “accredited investors” by virtue of their meeting one or more of the above standards; or ____ an individual who is a director or executive officer of Generation Hemp, Inc.

Appears in 1 contract

Samples: Subscription Agreement (Generation Hemp, Inc.)

Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status or Certificate of Non-U.S. Investor Status, as applicable (Exhibits B and C, respectively, included herewith.) Name (please print):): ___________________________________________________________________ If entity named above, By:: ___________________________________________________________________ Its:: ___________________________________________________________________ Social Security or Taxpayer I.D. Number:: ___________________________________________________________________ Business Address (including zip code):______________________________________ _____________): ___________________________________________________________________ Business Phone:: ___________________________________________________________________ Residence Address (including zip code):): ___________________________________________________________________ _____________Email Address: ___________________________________________________________________ Residence Phone:: All communications to be sent to: _______________Business or ___________________________________Residence Address _____________ All communications to be sent to: _____ Business or _____ Residence Address Email Please indicate below the form in which you will hold title to your interest in the SharesShares and Warrants. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND/OR WARRANTS AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the SharesShares and Warrants, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investorinves­tor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL ______NDIVIDUAL OWNERSHIP (one signature required) _____ ______JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ ______COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ ______TENANTS IN COMMON (both or all parties must sign) _____ ______GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ ______LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ ______LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ ______CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her her/its subscription for participation in the Shares purchase of Securities of the Company, this 24th 12 day of MayAugust, 2004, at Scranton, PA2013. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- PARTICIPANT ______________________________ ______________________________ (Signature) TitleBy: General Partner ___________________________ Its:____________________________ The Company has accepted this subscription this 24th 12 day of May 2004August, 2013 “COMPANY” PEDEVCO CORP., a Texas corporation By:____________________________ Xxxxx X. Xxxxxxxxxx Chief Executive Officer Address for notice: PEDEVCO Corp. 0000 Xxxxxxxxx Xxxxx Xxxxxx, Xxxxx 000 Xxxxxxxx, Xxxxxxxxxx 00000 Attn: Corporate Counsel Exhibit A Form of Warrant Exhibit B

Appears in 1 contract

Samples: Common Stock and Warrant (Pedevco Corp)

Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit A, included herewith.) Name (please print):__________________________________________________________ If entity named above, By:_____________________________________________________ Its:_____________________________________________________ Social Security or Taxpayer I.D. Number:__________________________________________ Business Address (including zip code):___________________________________________ _________________________________________________________________________ Business Phone: ____________________________________________________________ Business Phone:__________ Subscription Agreement Participant’s Initials 5 Trxade Group, Inc. Residence Address (including zip code):__________________________________________ _________________________________________________________________________ Residence Address (including zip code):_____________________________________ ___________________Email Address:_____________________________________________________________ Residence Phone:_______________________________________________________________ All communications to be sent to: _____ __Business or ______ Residence Address ________ Email Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's ’s domicile and his or her particular personal circumstances. ______ INDIVIDUAL OWNERSHIP (one signature required) ______ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) ______ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) ______ TENANTS IN COMMON (both or all parties must sign) ______ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) ______ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) ______ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) ______ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) ______ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) __________ Subscription Agreement Participant’s Initials 6 Trxade Group, Inc. Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th _______ day of May_____, 2004, at Scranton, PA2019. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004.PARTICIPANT

Appears in 1 contract

Samples: Contribution Agreement (Trxade Group, Inc.)

Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit B, included herewith.) Name (please print):___________________________________________________________________ If entity named above, By:_____________________________________________________________ Its:_____________________________________________________________ Social Security or Taxpayer I.D. Number:___________________________________________________ Business Address (including zip code):____________________________________________________ __________________________________________________________________________________ Business Phone:_____________________________________________________________________ Residence Address (including zip code):___________________________________________________ __________________________________________________________________________________ Email Address:_______________________________________________________________________ Residence Phone:_____________________________________________________________________ All communications to be sent to: ______ Business or ________ Residence Address ________ Email Please indicate below the form in which you will hold title to your interest in the SharesUnits. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND/OR WARRANTS AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTIONSUBSCRIPTION OR APPLICABLE LAW, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the SharesUnits, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investorinves­tor's domicile and his or her particular personal circumstances. _______ INDIVIDUAL OWNERSHIP (one signature required) _______ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _______ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _______ TENANTS IN COMMON (both or all parties must sign) _______ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _______ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _______ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _______ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her her/its subscription for participation in the Shares purchase of Securities of the Company, this 24th 28th day of MayNovember, 20042014. PARTICIPANT __________________________________ (Signature By:_______________________________ If Entity, at Scranton, PA. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner Entity Name:_________________ Its:_______________________________ The Company has accepted this subscription this 24th 28th day of May 2004.November 2014

Appears in 1 contract

Samples: Common Stock and Warrant (Pedevco Corp)

Investor Information. (The information below should This must be consistent with the form of ownership selected below.) below and the information provided in the Certificate of Accredited Investor Status (Annex A hereto). Name (please print):___________________________________________________________ If entity named above, By:: __________________________________________________ Its:: __________________________________________________ Social Security or Taxpayer I.D. Number:: ________________________________________ Business Address (including zip code):______________________________________ _____________________________________): ___________________________________________ Business Phone:___: _____________________________________________________________ Residence Address (including zip code):_____________________________________ ______________________________________): __________________________________________ Residence Phone:________: _______________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Offered Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE OFFERED SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Offered Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's inves­tor’s domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Offered Shares of the Company, this 24th _______ day of May, 2004________________, at Scranton, PA. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004_________________________.

Appears in 1 contract

Samples: Subscription Agreement (TWL Corp)

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Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit A, included herewith.) Name (please print):_________________________________________________________________________________________ If entity named above, By:____________________________________________________________________________________ Its:____________________________________________________________________________________ Social Security or Taxpayer I.D. Number:___________________________________ Business Address (including zip code):_______________________________________ ______Business Address (including zip code):__________________________________________________________________________ Business Phone:________________________________________________________________ Residence Address (including zip code):_____________________________________ _______Residence Address (including zip code):_________________________________________________________________________ Residence Phone:__________________________________________________________________________________________ Email:___________________________________________________________________________________________________ All communications to be sent to: :______________________________________________________________________________ __ Business or __ Residence Address Number of Shares subscribed for at [$X.XX per share]:______________________________________________________________ Residence Address Total Subscription Amount: $ _________________________________________________________________________________ Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investorinves­tor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th _______ day of May________, 20042008, at Scranton, PA_________________________. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004.PARTICIPANT

Appears in 1 contract

Samples: Subscription Agreement (Procera Networks Inc)

Investor Information. (The information below should be consistent with the form of ownership selected below.) Name (please print):____________________________________________________________ If entity named above, By:_____________________________________________________ Its:____________________________________________________ Social Security or Taxpayer I.D. Number:________________________________________ Business Address (including zip code):__________________________________________ ________________________________________________________________________________ Business Phone:_________________________________________________________________ Residence Address (including zip code):_________________________________________ ________________________________________________________________________________ Residence Phone:________________________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th ____ day of Mayof, 20042003, at Scranton, PAat______________,_______________. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner _______________________________ Participant The Company has accepted this subscription this 24th ____ day of May 2004__________, 2003.

Appears in 1 contract

Samples: Procera Networks Inc

Investor Information. (The information below should be consistent with the form of ownership selected below.) Name (please print):____________________________________________________________ If entity named above, By:_____________________________________________________ Its:____________________________________________________ Social Security or Taxpayer I.D. Number:________________________________________ Business Address (including zip code):__________________________________________ ________________________________________________________________________________ Business Phone:_________________________________________________________________ Residence Address (including zip code):_________________________________________ ________________________________________________________________________________ Residence Phone:________________________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th ____ day of Mayof, 20042003, at Scranton, PAat______________,_______________. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner _______________________________ Participant The Company has accepted this subscription this 24th 5th day of May 2004December, 2003.

Appears in 1 contract

Samples: Procera Networks Inc

Investor Information. (The information below should This must be consistent with the form of ownership selected belowbelow and the information provided in the Certificate of Accredited Investor Status (Exhibit A, included herewith.) Name (please print):__________________________________________________________ If entity named above, By:_____________________________________________________ Its:_____________________________________________________ Social Security or Taxpayer I.D. Number:__________________________________________ Business Address (including zip code):___________________________________________ _________________________________________________________________________ Business Phone: ____________________________________________________________ Business Phone:___________ Subscription Agreement Participant’s Initials 5 Trxade Group, Inc. Residence Address (including zip code):__________________________________________ _________________________________________________________________________ Residence Address (including zip code):_____________________________________ ___________________Email Address:_____________________________________________________________ Residence Phone:_______________________________________________________________ All communications to be sent to: _____ __Business or ______ Residence Address ________ Email Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers Participants should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's ’s domicile and his or her particular personal circumstances. ______ INDIVIDUAL OWNERSHIP (one signature required) ______ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) ______ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) ______ TENANTS IN COMMON (both or all parties must sign) ______ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign) ______ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign) ______ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign) ______ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign) ______ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) ___________ Subscription Agreement Participant’s Initials 6 Trxade Group, Inc. Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th _______ day of May_____, 2004, at Scranton, PA2019. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner The Company has accepted this subscription this 24th day of May 2004.PARTICIPANT

Appears in 1 contract

Samples: Trxade Group (Trxade Group, Inc.)

Investor Information. (The information below should be consistent with the form of ownership selected below.) Name (please print):): ________________________________________________________________ If entity named above, By:: ___________________________________________________________ Its:: ___________________________________________________________ Number of Shares _____________ Check enclosed in the amount of $ ______________ Social Security or Taxpayer I.D. Number:: _______________________________________________ Business Address (including zip code):): _________________________________________________ ________________________________________________________________________________ Business Phone:_____: ( ) ___________________________________________________________ Residence Address (including zip code):): ________________________________________________ ________________________________________________________________________________ Residence Phone:_____: ( ) __________________________________________________________ All communications to be sent to: _____ Business or _____ Residence Address Please indicate below the form in which you will hold title to your interest in the Shares. PLEASE CONSIDER CAREFULLY. ONCE YOUR SUBSCRIPTION IS ACCEPTED, A CHANGE IN THE FORM OF TITLE CONSTITUTES A TRANSFER OF THE INTEREST IN THE SHARES AND MAY THEREFORE BE RESTRICTED BY THE TERMS OF THIS SUBSCRIPTION, THE MEMORANDUM OR THE SHARES AND MAY RESULT IN ADDITIONAL COSTS TO YOU. Subscribers should seek the advice of their attorneys in deciding in which of the forms they should take ownership of the interest in the Shares, because different forms of ownership can have varying gift tax, estate tax, income tax, and other consequences, depending on the state of the investor's domicile and his or her particular personal circumstances. _____ INDIVIDUAL OWNERSHIP (one signature required) _____ JOINT TENANTS WITH RIGHT OF SURVIVORSHIP AND NOT AS TENANTS IN COMMON (both or all parties must sign) _____ COMMUNITY PROPERTY (one signature required if interest held in one name, i.e., managing spouse; two signatures required if interest held in both names) _____ TENANTS IN COMMON (both or all parties must sign) _____ GENERAL PARTNERSHIP (fill out all documents in the name of the PARTNERSHIP, by a PARTNER authorized to sign, and include a copy of the Partnership Agreement) _____ LIMITED PARTNERSHIP (fill out all documents in the name of the LIMITED PARTNERSHIP, by a GENERAL PARTNER authorized to sign, and include a copy of the Limited Partnership Agreement and any other document showing that the investment is authorized) _____ LIMITED LIABILITY COMPANY (fill out all documents in the name of the LIMITED LIABILITY COMPANY, by a member authorized to sign, and include a copy of the LIMITED LIABILITY COMPANY’s Operating Agreement and any other documents necessary to show the investment is authorized.) _____ CORPORATION (fill out all documents in the name of the CORPORATION, by the President or other officer authorized to sign, and include a copy of the Corporation's Articles and certified Corporate Resolution authorizing the signature) _____ TRUST (fill out all documents in the name of the TRUST, by the Trustee, and include a copy of the instrument creating the trust and any other documents necessary to show the investment by the Trustee is authorized. The date of the trust must appear on the Notarial where indicated.) Subject to acceptance by the Company, the undersigned has completed this Subscription Agreement to evidence his/her subscription for participation in the Shares of the Company, this 24th day of May, 2004, at Scranton, PA. LINDEN GROWTH PARTNERS By: Paul J. Coviello /s/ Xxxx X. Xxxxxxxo ----------------------------------- (Signature) Title: General Partner Subscriber The Company has accepted this subscription this 24th day of May , 2004.. Verdisys, Inc., a California Corporation By

Appears in 1 contract

Samples: Verdisys Inc

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