PLEASE COMPLETE THE FOLLOWING. The undersigned hereby represents and warrants to the Company that the answers to the following questions are true and correct and that the Company may rely on such answers in deciding whether to accept this subscription.
PLEASE COMPLETE THE FOLLOWING. 1. The exercise of this Warrant was solicited by The Thornwater Company, L.P. [ ]
PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by Network 1 Financial Securities, Inc., please check the following box. |_|
PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by Xxxxxx Xxxxxxxxx Wise & Company, please check the following box. |_|
PLEASE COMPLETE THE FOLLOWING. 1. If the exercise of this Warrant was solicited by Maidstone Financial, Inc., please check the following box. [ ]
PLEASE COMPLETE THE FOLLOWING. Has the Company or any of its Authorised Representatives or other representatives had a request for media accreditation (whether issued by DataCo or any other entity) declined, suspended or withdrawn? If “Yes”, please provide further details. Yes No
PLEASE COMPLETE THE FOLLOWING. I prepared all of the pleadings and papers to be filed in this case myself, and no one has been, or will be, paid on my behalf. I have not paid anyone or any organization for the preparation and processing of these documents or for the forms to be used in this case. I further declare that I am the person above named, that I have read the foregoing questions and information and know the same to be true to the best of my knowledge, and that IF ANY PART OF THE ABOVE IS MADE FALSELY, I AM SUBJECT TO PROSECUTION FOR PERJURY. (Signature of Affiant) SUBSCRIBED AND SWORN TO before me, a notary public, this day of , 20 . Notary Public for State of Montana Residing at My Commission Expires: Hon. Fourth Judicial District Missoula County Courthouse 000 Xxxx Xxxxxxxx Missoula, Montana 59802 (000) 000-0000 Fax (000) 000-0000 MONTANA FOURTH JUDICIAL DISTRICT COURT MISSOULA COUNTY In re the Marriage of: , Co-Petitioner, and , Co-Petitioner. Dept. No. Cause No.: DR- ORDER ON INABILITY TO PAY FILING FEES AND OTHER COSTS Having considered the information contained in [ ] Wife [ ] Husband Co-Petitioner’s Affidavit of Inability to Pay Filing Fees and Other Costs, IT IS XXXXXX ORDERED that, pursuant to §00-00-000, MCA et seq., all officers of the Court shall perform all services associated with this action, including filing, issuance and service of all pleadings and Court orders, without demanding or receiving fees in advance. Leave to file the Petition expires thirty (30) days from the date of this Order. Dated this day of , 20 . DISTRICT COURT JUDGE FORM #216 Name Address City State Zip Code Phone Number Email Address WIFE, CO-PETITIONER PRO SE Name Address City State Zip Code Phone Number Email Address HUSBAND, CO-PETITIONER PRO SE
PLEASE COMPLETE THE FOLLOWING. (a) The Business Day on which such Loan is to occur is __________, 2013.
PLEASE COMPLETE THE FOLLOWING. If the undersigned Management Stockholder intends to purchase shares of Purchased Stock (as defined in the Management Stockholder’s Agreement), please provide this number of shares of Purchased Stock. As specified in the Management Stockholder’s Agreement, this Purchased Stock has a base price of $5.00. If the undersigned Management Stockholder does not intend to purchase shares of Purchased Stock, please enter “N/A”: By executing this Schedule, the undersigned Management Stockholder accepts and agrees to be bound by and subject to the terms and conditions of, and makes the representations, warranties and agreements set forth in the New Agreements. The parties to each such New Agreement shall treat the execution and delivery hereof by the undersigned Management Stockholder as the execution and delivery of such New Agreement by the undersigned Management Stockholder, and, upon receipt and acceptance of this Schedule by such parties, the signature of the undersigned Management Stockholder set forth below shall constitute a counterpart to the signature page of each such New Agreement. Management Stockholder Dated: November , 2005 ACCEPTED BY: ACCELLENT HOLDINGS CORP. By: Name: Title: Dated: November , 2005
PLEASE COMPLETE THE FOLLOWING. 1. The exercise of this Warrant was solicited by Nutmeg Securities, Ltd.
