NONE OF THE SECURITIES TO WHICH THIS PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT
(THE “SUBSCRIPTION AGREEMENT”) RELATES HAVE BEEN REGISTERED UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED (THE “1933 ACT”), OR ANY U.S. STATE
SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD IN THE
UNITED STATES OR TO U.S. PERSONS (AS DEFINED HEREIN) EXCEPT PURSUANT TO AN
EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE
STATE SECURITIES LAWS.

PRIVATE PLACEMENT SUBSCRIPTION AGREEMENT 
(United States Accredited Subscribers Only)

TO:  ETHOS ENVIRONMENTAL, INC. (the “Company”)
         7015 ALAMITOS AVE
SAN DIEGO, CA 92154 USA

Purchase of Shares

1.  Subscription

1.1  The undersigned, namely, Sonia Dominguez, (the “Subscriber”) hereby
irrevocably subscribes for and agrees to purchase from the Company, on the basis
of the representations and warranties and subject to the terms and conditions
set forth herein, 50,000 common shares in the capital of the Company (the
“Shares”) at the price of US$1.00 per Share (such subscription and agreement to
purchase being the “Subscription”) for the total purchase price of $50,000 (the
“Subscription Proceeds”) which is tendered herewith, on the basis of the
representations and warranties and subject to the terms and conditions set forth
herein.

1.2  Subject to the terms hereof, the Subscription will be effective upon its
acceptance by the Company. The Subscriber acknowledges that the offering of the
Shares contemplated hereby is part a private placement of Shares having an
aggregate subscription level of US$50,000 (the “Offering”). The Offering is not
subject to any minimum aggregate subscription level.

2.  Payment

2.1  The Subscription Proceeds must accompany this Subscription and shall be
paid by certified check or bank draft drawn on a U.S. national bank made payable
and delivered to the Company. Alternatively, the Subscription Proceeds may be
wired to the Company to the wiring instructions that are provided in this
Subscription Agreement.

2.2  The Subscriber acknowledges and agrees that this Subscription Agreement,
the Subscription Proceeds and any other documents delivered in connection
herewith will be held on behalf of the Company. In the event that this
Subscription Agreement is not accepted by the Company for whatever reason, which
the Company expressly reserves the right to do, within 30 days of the delivery
of an executed Subscription Agreement by the Subscriber, this Subscription
Agreement, the Subscription Proceeds (without interest thereon) and any other
documents delivered in connection herewith will be returned to the Subscriber at
the address of the Subscriber as set forth in this Subscription Agreement.
2.3  Where the Subscription Proceeds are paid to the Company, the Company is
entitled to treat such Subscription Proceeds as an interest free loan to the
Company until such time as the Subscription is accepted and the certificates
representing the Shares have been issued to the Subscriber.
     
3.       Questionnaire and Undertaking and Direction
 
3.1 The Subscriber must complete, sign and return to the Company the following
documents:

(a)       two (2) executed copies of this Subscription Agreement; and

    (b)       a Prospective Investor Suitability Questionnaire in the form
attached as Appendix 1 (the   “Questionnaire”).

3.2   The Subscriber shall complete, sign and return to the Company as soon as
possible, on request by the Company, any documents, questionnaires, notices and
undertakings as may be required by regulatory authorities, stock exchanges and
applicable law.
  
4.       Closing 

4.1 Closing of the offering (the “Offering”) of the Shares (the “Closing”) shall
occur on March ___, 2007, or on such other date as may be determined by the
Company (the “Closing Date”).
 
5.       Acknowledgements of Subscriber 
 
5.1       The Subscriber acknowledges and agrees that:
 
   (a)       the Shares have not been registered under the 1933 Act, or under
any state securities or  “blue sky” laws of any state of the United States, and
are being offered only in a transaction not involving  any public offering
within the meaning of the 1933 Act, and, unless so registered, may not be
offered or  sold in the United States or to U.S. Persons (as defined herein),
except pursuant to an effective registration  statement under the 1933 Act, or
pursuant to an exemption from, or in a transaction not subject to, the
 registration requirements of the 1933 Act, and in each case only in accordance
with applicable state  securities laws;
 
   (b)       the Company will refuse to register any transfer of the Shares not
made in accordance  with the provisions of Regulation S, pursuant to an
effective registration statement under the 1933 Act or  pursuant to an available
exemption from, or in a transaction not subject to, the registration
requirements of  the 1933 Act;
 
   (c)       the Company has not undertaken, and will have no obligation, to
register any of the  Shares under the 1933 Act;
 
   (d)       the decision to execute this Subscription Agreement and purchase
the Shares agreed to  be purchased hereunder has not been based upon any oral or
written representation as to fact or otherwise  made by or on behalf of the
Company and such decision is based entirely upon a review of information  (the
“Company Information”) which has been provided by the Company to the Subscriber.
If the Company  has presented a business plan or any other type of corporate
profile to the Subscriber, the Subscriber  acknowledges that the business plan,
the corporate profile and any projections or predictions contained in  any such
documents may not be achieved or be achievable;
 
   (e)       the Subscriber and the Subscriber's advisor(s) have had a
reasonable opportunity to ask  questions of and receive answers from the Company
regarding the Offering, and to obtain additional  information, to the extent
possessed or obtainable without unreasonable effort or expense, necessary to
 verify the accuracy of the information contained in the Company Information, or
any business plan,  corporate profile or any other document provided to the
Subscriber;

(f)       the books and records of the Company were available upon reasonable
notice for  inspection, subject to certain confidentiality restrictions, by the
Subscriber during reasonable business  hours at its principal place of business
and that all documents, records and books pertaining to this  Offering have been
made available for inspection by the Subscriber, the Subscriber's attorney
and/or  advisor(s);
 
(g)       by execution hereof the Subscriber has waived the need for the Company
to  communicate its acceptance of the purchase of the Shares pursuant to this
Subscription Agreement;
 
(h)       the Company is entitled to rely on the representations and warranties
and the statements  and answers of the Subscriber contained in this Subscription
Agreement and in the Questionnaire, and the  Subscriber will hold harmless the
Company from any loss or damage it may suffer as a result of the  Subscriber's
failure to correctly complete this Subscription Agreement or the Questionnaire;
 
(i)       the Subscriber will indemnify and hold harmless the Company and, where
applicable, its  respective directors, officers, employees, agents, advisors and
shareholders from and against any and all  loss, liability, claim, damage and
expense whatsoever (including, but not limited to, any and all fees, costs  and
expenses whatsoever reasonably incurred in investigating, preparing or defending
against any claim,  lawsuit, administrative proceeding or investigation whether
commenced or threatened) arising out of or  based upon any representation or
warranty of the Subscriber contained herein, the Questionnaire or in any  other
document furnished by the Subscriber to the Company in connection herewith,
being untrue in any  material respect or any breach or failure by the Subscriber
to comply with any covenant or agreement  made by the Subscriber to the Company
in connection therewith;
 
(j)       the issuance and sale of the Shares to the Subscriber will not be
completed if it would be  unlawful or if, in the discretion of the Company
acting reasonably, it is not in the best interests of the  Company;
 
(k)       the Subscriber has been advised to consult its own legal, tax and
other advisors with  respect to the merits and risks of an investment in the
Shares and with respect to applicable resale  restrictions and it is solely
responsible (and the Company is in any way responsible) for compliance with
 applicable resale restrictions;
 
(l)       the Shares are not listed on any stock exchange or automated dealer
quotation system  and no representation has been made to the Subscriber that any
of the Shares will become listed on any  stock exchange or automated dealer
quotation system, except that currently certain market makers make  market in
shares of the Company on the National Association of Securities Dealers Inc.'s
OTC Bulletin  Board;
 
(m)       neither the SEC nor any other securities commission or similar
regulatory authority has  reviewed or passed on the merits of the Shares;
 
(n)       no documents in connection with this Offering have been reviewed by
the SEC or any  state securities administrators;
 
(o)       there is no government or other insurance covering any of the Shares;
and
 
(p)       this Subscription Agreement is not enforceable by the Subscriber
unless it has been  accepted by the Company, and the Subscriber acknowledges and
agrees that the Company reserves the  right to reject any Subscription for any
reason.

6.       Representations, Warranties and Covenants of the Subscriber
 
6.1 The Subscriber hereby represents and warrants to and covenants with the
Company (which representations, warranties and covenants shall survive the
Closing) that:
   
(a)       the Subscriber is resident in the United States;

(b)       the Subscriber has received and carefully read this Subscription
Agreement;

(c)       the Subscriber has the legal capacity and competence to enter into and
execute this  Subscription Agreement and to take all actions required pursuant
hereto and, if the Subscriber is a  corporation, it is duly incorporated and
validly subsisting under the laws of its jurisdiction of incorporation  and all
necessary approvals by its directors,  shareholders and others have been
obtained to authorize  execution and performance of this Subscription Agreement
on behalf of the Subscriber;

(d)       the Subscriber (i) has adequate net worth and means of providing for
its current financial  needs and possible personal contingencies, (ii) has no
need for liquidity in this investment, and (iii) is able  to bear the economic
risks of an investment in the Shares for an indefinite period of time, and can
afford  the complete loss of such investment;

(e)       the Subscriber is aware that an investment in the Company is
speculative and involves  certain risks, including the possible loss of the
investment;

(f)       the entering into of this Subscription Agreement and the transactions
contemplated  hereby do not result in the violation of any of the terms and
provisions of any law applicable to, or, if  applicable, the constating
documents of, the Subscriber, or of any agreement, written or oral, to which the
 Subscriber may be a party or by which the Subscriber is or may be bound;

(g)       the Subscriber has duly executed and delivered this Subscription
Agreement and it  constitutes a valid and binding agreement of the Subscriber
enforceable against the Subscriber;
 
(h)       the Subscriber has the requisite knowledge and experience in financial
and business  matters as to be capable of evaluating the merits and risks of the
investment in the Shares and the  Company, and the Subscriber is providing
evidence of such knowledge and experience in these matters  through the
information requested in the Questionnaire;
 
(i)       the Subscriber understands and agrees that the Company and others will
rely upon the  truth and accuracy of the acknowledgements, representations and
agreements contained in this  Subscription Agreement, and agrees that if any of
such acknowledgements, representations and  agreements are no longer  accurate
or have been breached, the Subscriber shall promptly notify the  Company;
 
(j)       All information contained in the Questionnaire is complete and
accurate and may be  relied upon by the Company, and the Subscriber will notify
the Company immediately of any material  change in any such information
occurring prior to the closing of the purchase of the Shares;
 
(k)       the Subscriber is purchasing the Shares for its own account for
investment purposes only  and not for the account of any other person and not
for distribution, assignment or resale to others, and no  other person has a
direct or indirect beneficial interest is such Shares, and the Subscriber has
not  subdivided his interest in the Shares with any other person;
 
(l)       the Subscriber is not an underwriter of, or dealer in, the common
shares of the Company,  nor is the Subscriber participating, pursuant to a
contractual agreement or otherwise, in the distribution of  the Shares;
 
(m)       the Subscriber has made an independent examination and investigation
of an investment  in the Shares and the Company and has depended on the advice
of its legal and financial advisors and  agrees that the Company will not be
responsible in anyway whatsoever for the Subscriber's decision to  invest in the
Shares and the Company;
 
(n)       if the Subscriber is acquiring the Shares as a fiduciary or agent for
one or more investor  accounts, the investor accounts for which the Subscriber
acts as a fiduciary or agent satisfy the definition  of an “Accredited
Investor”, as the term is defined under Regulation D of the 1933 Act;
 
(o)       if the Subscriber is acquiring the Shares as a fiduciary or agent for
one or more investor  accounts, the Subscriber has sole investment discretion
with respect to each such account, and the  Subscriber has full power to make
the foregoing acknowledgements, representations and agreements on  behalf of
such account;
 
(p)       the Subscriber is not aware of any advertisement of any of the Shares
and is not  acquiring the Shares as a result of any form of general solicitation
or general advertising including  advertisements, articles, notices or other
communications published in any newspaper, magazine or similar  media or
broadcast over radio or television, or any seminar or meeting whose attendees
have been invited  by general solicitation or general advertising; and
 
(q)       no person has made to the Subscriber any written or oral
representations:
 
    (i)       that any person will resell or repurchase any of the Shares;
 
    (ii)       that any person will refund the purchase price of any of the
Shares;
 
    (iii)       as to the future price or value of any of the Shares; or
 
(iv)       that any of the Shares will be listed and posted for trading on any
stock  exchange or automated dealer quotation system or that application has
been made to list and post  any of the Shares of the Company on any stock
exchange or automated dealer quotation system.
  
6.2 In this Subscription Agreement, the term “U.S. Person” shall have the
meaning ascribed thereto in Regulation S and for the purpose of the Subscription
includes any person in the United States.
     
7.       Acknowledgement and Waiver
 
7.1       The Subscriber has acknowledged that the decision to purchase the
Shares was solely made on the basis of publicly available information. The
Subscriber hereby waives, to the fullest extent permitted by law, any rights of
withdrawal, rescission or compensation for damages to which the Subscriber might
be entitled in connection with the distribution of any of the Shares.
 
8. Representations and Warranties will be Relied Upon by the Company
 
8.1       The Subscriber acknowledges that the representations and warranties
contained herein are made by it with the intention that they may be relied upon
by the Company and its legal counsel in determining the Subscriber's eligibility
to purchase the Shares under applicable securities legislation, or (if
applicable) the eligibility of others on whose behalf it is contracting
hereunder to purchase the Shares under applicable securities legislation.
  
The Subscriber further agrees that by accepting delivery of the certificates
representing the Shares on the Closing Date, it will be representing and
warranting that the representations and warranties contained herein are true and
correct as at the Closing Date with the same force and effect as if they had
been made by the Subscriber at the Closing Date and that they will survive the
purchase by the Subscriber of Shares and will continue in full force and effect
notwithstanding any subsequent disposition by the Subscriber of such Shares.

9.       Resale Restrictions 
 
9.1       The Subscriber acknowledges that any resale of the Shares will be
subject to resale restrictions contained in the securities legislation
applicable to each Subscriber or proposed transferee. The Subscriber
acknowledges that the Shares have not been registered under the 1933 Act of the
securities laws of any state of the United States and that the Company does not
intend to register same under the 1933 Act, or the securities laws of any such
state and has no obligation to do so. The Shares may not be offered or sold in
the United States unless registered in accordance with federal securities laws
and all applicable state securities laws or exemptions from such registration
requirements are available.
 
10.       Legending and Registration of Subject Shares
 
10.1       The Subscriber hereby acknowledges that that upon the issuance
thereof, and until such time as the same is no longer required under the
applicable securities laws and regulations, the certificates representing any of
the Shares will bear a legend in substantially the following form:

“NONE OF THE SECURITIES REPRESENTED HEREBY HAVE BEEN REGISTERED UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED (THE “1933 ACT”), OR ANY U.S. STATE
SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD EXCEPT
PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE 1933 ACT OR PURSUANT
TO AN EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE
STATE SECURITIES LAWS.”

The Subscriber hereby acknowledges and agrees to the Company making a notation
on its records or giving instructions to the registrar and transfer agent of the
Company in order to implement the restrictions on transfer set forth and
described in this Subscription Agreement.

11.       Costs
 
11.1       The Subscriber acknowledges and agrees that all costs and expenses
incurred by the Subscriber (including any fees and disbursements of any special
counsel retained by the Subscriber) relating to the purchase of the Shares shall
be borne by the Subscriber.
    
11.2 The Subscriber hereby acknowledges and agrees to the Company making a
notation on its records or giving instructions to the registrar and transfer
agent of the Company in order to implement the restrictions on transfer set
forth and described in this Subscription Agreement.

12.  Governing Law
 
12.1       This Subscription Agreement is governed by the laws of the State of
Nevada and the federal laws of the United States of America applicable therein.
The Subscriber, in its personal or corporate capacity and, if applicable, on
behalf of each beneficial purchaser for whom it is acting, irrevocably agrees to
the jurisdiction of the State of Nevada.
13. Survival  
  
13.1 This Subscription Agreement, including without limitation the
representations, warranties and covenants contained herein, shall survive and
continue in full force and effect and be binding upon the parties hereto
notwithstanding the completion of the purchase of the Shares by the Subscriber
pursuant hereto.  
   
14.   Assignment 
   
14.1   This Subscription Agreement is not transferable or assignable. 
  
15. Severability 
  
15.1   The invalidity or unenforceability of any particular provision of this
Subscription Agreement shall not affect or limit the validity or enforceability
of the remaining provisions of this Subscription Agreement.  
  
16.   Entire Agreement 
      
16.1   Except as expressly provided in this Subscription Agreement and in the
agreements, instruments and other documents contemplated or provided for herein,
this Subscription Agreement contains the entire agreement between the parties
with respect to the sale of the Shares and there are no other terms,
conditions, representations or warranties, whether expressed, implied, oral or
written, by statute or common law, by the Company or by anyone else. 

17.   Notices  
     
17.1 All notices and other communications hereunder shall be in writing and
shall be deemed to have been duly given if mailed or transmitted by any standard
form of telecommunication. Notices to the Subscriber shall be directed to the
address on the signature page of this Subscription Agreement and notices to the
Company shall be directed to it at the address written above, Attention: The
President; fax number: (619) 575-9300.

18.       Counterparts and Electronic Means
 
18.1       This Subscription Agreement may be executed in any number of
counterparts, each of which, when so executed and delivered, shall constitute an
original and all of which together shall constitute one instrument. Delivery of
an executed copy of this Agreement by electronic facsimile transmission or other
means of electronic communication capable of producing a printed copy will be
deemed to be execution and delivery of this Agreement as of the date hereinafter
set forth.

IN WITNESS WHEREOF, the Subscriber has duly executed this Subscription Agreement
as of the date hereinafter set forth.

DELIVERY AND REGISTRATION INSTRUCTIONS

1.     
Delivery - please deliver the Share certificates to:
 
 _________________________________________________________________
 
 _________________________________________________________________ 
 
  
2.     
Registration - registration of the certificates which are to be delivered at
closing should be made as follows:
        _________________________________________________________________
 
(name)
        _________________________________________________________________
 
(address)
  
3.     
The undersigned hereby acknowledges that he or she will deliver to the Company
all such additional completed forms in respect of the Subscriber's purchase of
the Shares as may be required for filing with the appropriate securities
commissions and regulatory authorities.
 

_________________________________________________________________
(Name of Subscriber - Please type or print)

_________________________________________________________________
(Signature and, if applicable, Office)

_________________________________________________________________
(Address of Subscriber)

_________________________________________________________________
(City, State, and Zip Code of Subscriber)

United States of America
_________________________________________________________________
(Country of Subscriber)

_________________________________________________________________
(Fax Number and email address)

ACCEPTANCE

The above-mentioned Subscription Agreement in respect of the Shares is hereby
accepted by Ethos Environmental, Inc.

DATED at __________________________________, the _______day of
__________________, 2007.

ETHOS ENVIRONMENTAL, INC.

___________________________________________
Title:
Authorized Signatory

--------------------------------------------------------------------------------

APPENDIX 1
 
ACCREDITED INVESTOR QUESTIONNAIRE

All capitalized terms herein, unless otherwise defined, have the meanings
ascribed thereto in the Subscription Agreement.

This Questionnaire is for use by each Subscriber who is a US person (as that
term is defined Regulation S of the United States Securities Act of 1933 (the
“1933 Act”)) and has indicated an interest in purchasing Shares of ETHOS
ENVIRONMENTAL, INC. (the “Company”). The purpose of this Questionnaire is to
assure the Company that each Subscriber will meet the standards imposed by the
1933 Act and the appropriate exemptions of applicable state securities laws. The
Company will rely on the information contained in this Questionnaire for the
purposes of such determination. The Shares will not be registered under the 1933
Act in reliance upon the exemption from registration afforded by Section 3(b)
and/or Section 4(2) and Regulation D of the 1933 Act. This Questionnaire is not
an offer of the Shares or any other securities of the Company in any state other
than those specifically authorized by the Company.

All information contained in this Questionnaire will be treated as confidential.
However, by signing and returning this Questionnaire, each Subscriber agrees
that, if necessary, this Questionnaire may be presented to such parties as the
Company deems appropriate to establish the availability, under the 1933 Act or
applicable state securities law, of exemption from registration in connection
with the sale of the Shares hereunder.

The Subscriber covenants, represents and warrants to the Company that it
satisfies one or more of the categories of “Accredited Investors”, as defined by
Regulation D promulgated under the 1933 Act, as indicated below: (Please initial
in the space provide those categories, if any, of an “Accredited Investor” which
the Subscriber satisfies)

______ Category 1 
An organization described in Section 501(c)(3) of the United States Internal
Revenue Code,
 
a corporation, a Massachusetts or similar business trust or partnership, not
formed for the specific
 
purpose of acquiring the Shares, with total assets in excess of US $5,000,000; 
______ Category 2 
A natural person whose individual net worth, or joint net worth with that
person's spouse, on the
 
date of purchase exceeds US $1,000,000; 
______ Category 3 
A natural person who had an individual income in excess of US $200,000 in each
of the two most
 
recent years or joint income with that person's spouse in excess of US $300,000
in each of those years and has a reasonable expectation of reaching the same
income level in the current year; 
______ Category 4 
A “bank” as defined under Section (3)(a)(2) of the 1933 Act or savings and loan
association or other institution as defined in Section 3(a)(5)(A) of the 1933
Act acting in its individual or fiduciary capacity; a broker dealer registered
pursuant to Section 15 of the Securities Exchange Act of 1934 (United States);
an insurance company as defined in Section 2(13) of the 1933 Act; an investment
company registered under the Investment Company Act of 1940 (United States) or a
business development company as defined in Section 2(a)(48) of such 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 (United
States); a plan with total assets in excess of $5,000,000 established and
maintained by a state, a political subdivision thereof, or an agency or
instrumentality of a state or a political subdivision thereof, for the benefit
of its employees; an employee benefit plan within the meaning of the Employee
Retirement Income Security Act of 1974 (United States) whose
investment decisions are 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, whose
investment decisions are made solely by persons that are accredited investors; 
______ Category 5 
A private business development company as defined in Section 202(a)(22) of the
Investment Advisers Act of 1940 (United States); 
______ Category 6 
A director or executive officer of the Company; 
______ Category 7 
A trust with total assets in excess of $5,000,000, not formed for the specific
purpose of acquiring the Shares, whose purchase is directed by a sophisticated
person as described in Rule 506(b)(2)(ii) under the 1933 Act; 
______ Category 8 
An entity in which all of the equity owners satisfy the requirements of one or
more of the foregoing categories; 
 
 

Note that prospective Subscribers claiming to satisfy one of the above
categories of Accredited Investor may be required to supply the Company with a
balance sheet, prior years' federal income tax returns or other appropriate
documentation to verify and substantiate the Subscriber's status as an
Accredited Investor.

If the Subscriber is an entity which initialed Category 8 in reliance upon the
Accredited Investor categories above, state the name, address, total personal
income from all sources for the previous calendar year, and the net worth
(exclusive of home, home furnishings and personal automobiles) for each equity
owner of the said entity:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The Subscriber hereby certifies that the information contained in this
Questionnaire is complete and accurate and the Subscriber will notify the
Company promptly of any change in any such information. If this Questionnaire is
being completed on behalf of a corporation, partnership, trust or estate, the
person executing on behalf of the Subscriber represents that it has the
authority to execute and deliver this Questionnaire on behalf of such entity.

IN WITNESS WHEREOF, the undersigned has executed this
Questionnaire as of March ______, 2007.  
     
If a Corporation, Partnership or Other Entity: 
 
 
If an Individual: 
 
 
 
 
 
 
____________________________________________
Print or Type Name of Entity 
 
 
_____________________________________________
Signature 
 
 
 
 
 
 
____________________________________________
Signature of Authorized Signatory 
 
 
_____________________________________________
Print or Type Name 
 
 
 
 
 
 
____________________________________________
Type of Entity
   
_____________________________________________
Social Security/Tax I.D. Number