Common use of Subscription Information Clause in Contracts

Subscription Information. Please complete the following information. Requested Subscription Amount: $_______________ (subject to Company acceptance) Name of Purchaser as it is to appear on the Senior Secured Convertible Promissory Note and Warrant Indicate ownership as: ____ (a) Individual ____ (b) Community Property ____ (c) Joint Tenants with Right of Survivorship ) All parties ____ (d) Tenants in Common ) must sign ____ (e) Corporate ____ (f) Partnership ____ (g) Trust ____________________________________ Address of Residence (or Business, if not an individual) __________________________________ Address for Sending Notices (if different) __________________________________ City, State and Zip Code __________________________________ City, State and Zip Code __________________________________ Telephone __________________________________ Telephone __________________________________ State of Residence (or State of Organization, if an entity) __________________________________ State of Residence (or State of Organization, if an entity) __________________________________ SSN/TIN __________________________________ SSN/TIN __________________________________ E-mail __________________________________ E-mail