SUBSCRIPTION AGREEMENT OXAMEDIA CORPORATION
Exhibit 99.1
OXAMEDIA CORPORATION
The undersigned subscriber (the “Subscriber”) hereby irrevocably subscribes for that number of shares of common stock (the “Shares”) of Oxamedia Corporation, a Delaware corporation (the “Company”), set forth below, upon and subject to the terms and conditions set forth in the Company’s Prospectus dated ___________, 20___, contained within the Company’s Form S-1 Registration Statement relating thereto filed with the United States Securities and Exchange Commission, to which this Subscription Agreement is attached.
Subscriber is a bona fide resident of the State of ____________ or the Country of ___________ (if Subscriber is non-US resident).
Total number of shares subscribed for at US $0.50 per share: ________________ shares.
Amount paid with this Subscription Agreement at a price of US $0.50 per Share: US $__________________.
This Subscription Agreement constitutes the entire agreement among the parties hereto with respect to the subject matter hereof and may be amended only by a writing executed by all parties.
IN WITNESS WHEREOF, the undersigned has executed this Subscription Agreement this _____ day of ________________, 2011.
Name of Entity (for Subscribers that are entities only):_________________________________ |
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Signature: _____________________________________________________________________ |
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Print Name: ___________________________________________________________________ |
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Print Title (for Subscribers that are entities only): _____________________________________ |
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Address: _____________________________________________________________________ |
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Telephone No.: ________________________________________________________________ |
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E-mail Address: ______________________________________________________________ |
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Subscriber’s US Social Security Number; Federal Employer Identification Number or |
Identification Number of home jurisdiction: _______________________________________ |
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Signature of Co-owners, if applicable: ____________________________________________ |
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Name as it should appear on the Certificate: ________________________________________ |
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If Joint Ownership, check one (all parties must sign above): |
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[ ] Joint Tenants with Right of Survivorship |
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[ ] Tenants in Common |
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[ ] Community Property |
If a Fiduciary or a Business Entity check one: |
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[ ] Trust -Authorized Person: _______________________ | Capacity: _______________ |
[ ] Estate -Authorized Person: _______________________ | Capacity: _______________ |
[ ] Corporation -Authorized Person: __________________ | Capacity: _______________ |
[ ] Limited Liability Company | Capacity: _______________ |
[ ] Partnership -Authorized Person: __________________ | Capacity: _______________ |
[ ] Other: ____________________ (Describe) | Capacity: _______________ |
PAYMENT BY CHECK OR MONEY ORDER INSTRUCTIONS
If Subscriber wishes to pay the purchase price of his or her Shares by check, all checks or money orders shall be made payable to: Oxamedia Corporation, ▇▇ ▇.▇. ▇▇▇ ▇▇▇., ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇, Tel. (▇▇▇) ▇▇▇-▇▇▇▇.
WIRE TRANSFER INSTRUCTIONS
If Subscriber wishes to wire transfer the purchase price of the Shares, wire transfer available funds in the amount of the purchase price subscribed for hereunder, as follows:
Bank:________________________________________________________________________ |
Account Name: ________________________________________________________________ |
Account No.: __________________________________________________________________ |
ABA Routing No.: _____________________________________________________________ |
SWIFT code: __________________________________________________________________ |
Bank Address: _______________________________________________________________ |
ACCEPTANCE OF SUBSCRIPTION
The foregoing Subscription is hereby accepted for and on behalf of Oxamedia Corporation this _____day of _____________, 2011.
OXAMEDIA CORPORATION |
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By: _______________________________________ |
Name: ______________ |
Title: _______________ |