Exhibit 10.35

 

SUBSCRIPTION AGREEMENT

 

THIS SUBSCRIPTION AGREEMENT (this “Agreement”), is dated as of __________ __,
2020, by and between GROM SOCIAL ENTERPRISES, INC., a Florida corporation (the
“Company”), and the subscriber identified on the signature page hereto (each a
“Subscriber” and collectively “Subscribers”).

 

WHEREAS, the Company and the Subscribers are executing and delivering this
Agreement in reliance upon an exemption from securities registration afforded by
the provisions of Section 4(2), Section 4(6) and/or Regulation D (“Regulation
D”) as promulgated by the United States Securities and Exchange Commission (the
“Commission”) under the Securities Act of 1933, as amended (the “1933 Act”); and

 

WHEREAS, the parties desire that, upon the terms and subject to the conditions
contained herein, the Company shall issue and sell to the Subscribers, as
provided herein, and the Subscribers, in the aggregate, shall purchase up to a
maximum of 10,000,000 shares, on a rolling basis, of Series B 8% Convertible
Preferred Stock of the Company (the “Preferred Stock”), the terms, preferences
and rights as described in the Certificate of Designation of the Series B
Convertible Preferred Stock which is annexed hereto as Exhibit A, convertible
into shares of the Company's Common Stock, $0.001 par value (the "Common
Stock"), as described therein. The per share purchase price of each share of
Preferred Stock shall be $1.00 per share (the “Purchase Price”). The Preferred
Stock and the shares of Common Stock issuable upon conversion of the Preferred
Stock (the “Conversion Shares”) are collectively referred to herein as the
"Securities".

 

NOW, THEREFORE, in consideration of the mutual covenants and other agreements
contained in this Agreement, the Company and the Subscribers hereby agree as
follows:

 

1.       Purchase; Closing Date. The Subscriber understands and acknowledges
that the Purchase Price to be remitted to the Company in exchange for the
Preferred Stock is as indicated on the signature page hereto. The Subscriber’s
delivery of this Agreement to the Company shall be accompanied by payment of the
Purchase Price, payable in United States Dollars, by wire transfer, or check of
immediately available funds delivered contemporaneously with the Subscriber’s
delivery of this Agreement to the Company in accordance with the wire
instructions provided on Exhibit C. The Subscriber understands and agrees that,
subject to Section 2 and applicable laws, by executing this Agreement, it is
entering into a binding agreement.

 

The “Closing Date” shall be the date that the Purchase Price is transmitted by
wire transfer or otherwise credited to or for the benefit of the Company and the
Company accepts the Purchase Price, as indicated by sending the Subscriber a
signature page to this Agreement, duly executed by the Company. Subject to the
satisfaction or waiver of the terms and conditions of this Agreement, on the
Closing Date, each Subscriber shall purchase and the Company shall sell to each
Subscriber the number of shares of Preferred Stock in the amount designated on
the signature page hereto for the Purchase Price indicated thereon.

 

The Subscriber agrees and acknowledges that there is no minimum amount to be
raised in this offering, and therefore the Company will accept the Purchase
Price upon the transmittal thereof. Accordingly, the Company may not raise
sufficient funds to effectuate its business plan.

 

The Subscriber further agrees and acknowledges that the majority of the shares
of the Preferred Stock to be issued shall be issued to current securityholders
of the Company who are converting their outstanding debt and equity securities
to shares of the Preferred Stock.

 

 

 

 1 

 

 

2.       Subscriber's Representations and Warranties. Each Subscriber hereby
represents and warrants to and agrees with the Company only as to such
Subscriber that:

 

(a)       Organization and Standing of the Subscribers. If the Subscriber is an
entity, such Subscriber is a corporation, partnership or other entity duly
incorporated or organized, validly existing and in good standing under the laws
of the jurisdiction of its incorporation or organization.

 

(b)       Authorization and Power. Each Subscriber has the requisite power and
authority to enter into and perform this Agreement and to purchase the Preferred
Stock being sold to it hereunder. The execution, delivery and performance of
this Agreement by such Subscriber and the consummation by it of the transactions
contemplated hereby and thereby have been duly authorized by all necessary
corporate or partnership action, and no further consent or authorization of such
Subscriber or its Board of Directors, stockholders, partners, members, trustees,
as the case may be, is required. This Agreement has been duly authorized,
executed and delivered by Subscriber and constitutes, or shall constitute when
executed and delivered, a valid and binding obligation of the Subscriber
enforceable against the Subscriber in accordance with the terms thereof.

 

(c)       No Conflicts. The execution, delivery and performance of this
Agreement and the consummation by such Subscriber of the transactions
contemplated hereby or relating hereto do not and will not (i) result in a
violation of such Subscriber’s charter documents or bylaws or other
organizational documents or (ii) conflict with, or constitute a default (or an
event which with notice or lapse of time or both would become a default) under,
or give to others any rights of termination, amendment, acceleration or
cancellation of any agreement, indenture or instrument or obligation to which
such Subscriber is a party or by which its properties or assets are bound, or
result in a violation of any law, rule, or regulation, or any order, judgment or
decree of any court or governmental agency applicable to such Subscriber or its
properties (except for such conflicts, defaults and violations as would not,
individually or in the aggregate, have a material adverse effect on such
Subscriber). Such Subscriber is not required to obtain any consent,
authorization or order of, or make any filing or registration with, any court or
governmental agency in order for it to execute, deliver or perform any of its
obligations under this Agreement or to purchase the Securities in accordance
with the terms hereof, provided that for purposes of the representation made in
this sentence, such Subscriber is assuming and relying upon the accuracy of the
relevant representations and agreements of the Company herein.

 

(d)       Information on Company. The Subscriber has been furnished with all
information it has requested from the Company and considered all factors the
Subscriber deems material in deciding on the advisability of investing in the
Securities. The Subscriber further understands that the Company has been filing
reports with the Commission. The Subscriber has been afforded the opportunity to
ask questions of and receive answers from duly authorized officers and/or other
representatives of the Company and any additional information which the
Subscriber had requested. The Subscriber has also reviewed all information
including the terms hereof and of the Preferred Stock, with their counsel and
professional tax or economic advisers and understands the risks relating hereto.

 

The Subscriber understands that the auditors of the Company have expressed their
concern as to the viability of the Company and issued a going concern opinion
with respect to the Company.

 

(e)       Information on Subscriber. The Subscriber is, and will be at the time
of the conversion of the Preferred Stock, an "accredited investor", as such term
is defined in Regulation D promulgated by the Commission under the 1933 Act, is
experienced in investments and business matters, has made investments of a
speculative nature and has purchased securities of companies in private
placements in the past and, with its representatives, has such knowledge and
experience in financial, tax and other business matters as to enable the
Subscriber to utilize the information made available by the Company to evaluate
the merits and risks of and to make an informed investment decision with respect
to the proposed purchase, which represents a speculative investment. The
Subscriber has the authority and is duly and legally qualified to purchase and
own the Securities. The Subscriber is able to bear the risk of such investment
for an indefinite period and to afford a complete loss thereof. The information
set forth on the signature page hereto and on the accredited investor
questionnaire annexed hereto as Exhibit B regarding the Subscriber is accurate.

 

 

 

 2 

 

 

(f)       Purchase of Preferred Stock. On the Closing Date, the Subscriber will
purchase the Preferred Stock as principal for its own account for investment
only and not with a view toward, or for resale in connection with, the public
sale or any distribution thereof. The Subscriber has been advised of and
acknowledges that (i) there is currently no market for the Preferred Stock being
purchased herein, and (ii) it is not intended that any market will develop for
the Preferred Stock.

 

(g)      Compliance with Securities Act. The Subscriber understands and agrees
that the Securities have not been registered under the 1933 Act or any
applicable state securities laws, by reason of their issuance in a transaction
that does not require registration under the 1933 Act (based in part on the
accuracy of the representations and warranties of Subscriber contained herein),
and that such Securities must be held indefinitely unless a subsequent
disposition is registered under the 1933 Act or any applicable state securities
laws or is exempt from such registration.

 

(h)      Experience of Subscriber. The Subscriber is (i) experienced in making
investments of the kind described in this Agreement and the related documents,
(ii) able, by reason of the business and financial experience of its officers
(if an entity) and professional advisors (who are not affiliated with or
compensated in any way by the Company or any of its affiliates or selling
agents), to protect its own interests in connection with the transactions
described in this Agreement, and the related documents, and (iii) able to afford
the entire loss of its investment in the Securities. The Subscriber’s overall
commitment to investments which are not readily marketable is not
disproportionate to the Subscriber's net worth, and an investment in the
Securities will not cause such overall commitment to become excessive.

 

(i)       No other representations. The Subscriber is not relying on the
Company, or its affiliates or agents with respect to economic considerations
involved in this investment. The Subscriber has relied solely on its own
advisors. No representations or warranties have been made to the Subscriber by
the Company, or any officer, employee, agent, affiliate or subsidiary of the
Company, other than the representations of the Company contained herein, and in
subscribing for the Securities the Subscriber is not relying upon any
representations other than those contained herein.

 

(j)       Shares Legend. The Preferred Stock and the Conversion Shares shall
bear the following or similar legend:

 

"THE SHARES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE
SECURITIES ACT OF 1933, AS AMENDED. THESE SHARES MAY NOT BE SOLD, OFFERED FOR
SALE, PLEDGED OR HYPOTHECATED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION
STATEMENT UNDER SUCH SECURITIES ACT OR ANY APPLICABLE STATE SECURITIES LAW OR AN
OPINION OF COUNSEL REASONABLY SATISFACTORY TO [THE COMPANY] THAT SUCH
REGISTRATION IS NOT REQUIRED."

 

(k)      Communication of Offer. The offer to sell the Securities was directly
communicated to the Subscriber by the Company. At no time was the Subscriber
presented with or solicited by any leaflet, newspaper or magazine article, radio
or television advertisement, or any other form of general advertising or
solicited or invited to attend a promotional meeting otherwise than in
connection and concurrently with such communicated offer.

 

(l)       Authority; Enforceability. This Agreement and other agreements
delivered together with this Agreement or in connection herewith have been duly
authorized, executed and delivered by the Subscriber and are valid and binding
agreements enforceable in accordance with their terms, subject to bankruptcy,
insolvency, fraudulent transfer, reorganization, moratorium and similar laws of
general applicability relating to or affecting creditors’ rights generally and
to general principles of equity; and Subscriber has full power and authority
necessary to enter into this Agreement and such other agreements and to perform
its obligations hereunder and under all other agreements entered into by the
Subscriber relating hereto.

 

(m)     Restricted Securities. Subscriber understands that the Securities have
not been registered under the 1933 Act and such Subscriber will not sell, offer
to sell, assign, pledge, hypothecate or otherwise transfer any of the Securities
unless pursuant to an effective registration statement under the 1933 Act, or
unless an exemption from registration is available. Notwithstanding anything to
the contrary contained in this Agreement, such Subscriber may transfer (with an
opinion of counsel satisfactory to the Company and its counsel) the Securities
to its Affiliates (as defined below), provided that each such Affiliate is an
“accredited investor” under Regulation D and such Affiliate agrees to be bound
by the terms and conditions of this Agreement. For the purposes of this
Agreement, an “Affiliate” of any person or entity means any other person or
entity directly or indirectly controlling, controlled by or under direct or
indirect common control with such person or entity. Affiliate includes each
subsidiary of the Company. For purposes of this definition, “control” means the
power to direct the management and policies of such person or firm, directly or
indirectly, whether through the ownership of voting securities, by contract or
otherwise.

 

 

 

 3 

 

 

(n)      No Governmental Review. Each Subscriber understands that no United
States federal or state agency or any other governmental or state agency has
passed on or made recommendations or endorsement of the Securities or the
suitability of the investment in the Securities nor have such authorities passed
upon or endorsed the merits of the offering of the Securities.

 

(o)      Correctness of Representations. Each Subscriber represents that the
foregoing representations and warranties are true and accurate as of the date
hereof and shall survive the issuance and delivery of the Conversion Shares. If,
in any respect, those representations and warranties shall not be true and
accurate prior to delivery of the payment pursuant to Section 1 above, the
undersigned shall immediately give written notice to the Company specifying
which representations and warranties are not true and accurate and the reason
therefor. It is specifically understood and agreed by the Subscriber that
neither the Company nor its officers or directors has made, nor by this
Agreement shall be construed to make, directly or indirectly, explicitly or by
implication, any representation, warranty, projection, assumption, promise,
covenant, opinion, recommendation or other statement of any kind or nature with
respect to the anticipated operations, investment returns, cash flows, profits
or losses of the Company.

 

(p)      Survival. The foregoing representations and warranties shall survive
the Closing Date for a period of three years.

 

3.       Company Representations and Warranties. The Company represents and
warrants to and agrees with each Subscriber that:

 

(a)       Due Incorporation. The Company is a corporation or other entity duly
incorporated or organized, validly existing and in good standing under the laws
of the State of Florida and has the requisite corporate power to own its
properties and to carry on its business as presently conducted.

 

(b)       Authority; Enforceability. This Agreement and any other agreements
delivered together with this Agreement or in connection herewith (collectively
“Transaction Documents”) have been duly authorized, executed and delivered by
the Company and are valid and binding agreements of the Company enforceable in
accordance with their terms, subject to bankruptcy, insolvency, fraudulent
transfer, reorganization, moratorium and similar laws of general applicability
relating to or affecting creditors' rights generally and to general principles
of equity. The Company has full corporate power and authority necessary to enter
into and deliver the Transaction Documents and to perform its obligations
thereunder.

 

(c)       Consents. No consent, approval, authorization or order of any court,
governmental agency or body or arbitrator having jurisdiction over the Company,
or any of its Affiliates nor the Company's shareholders is required for the
execution by the Company of the Transaction Documents and compliance and
performance by the Company of its obligations under the Transaction Documents,
including, without limitation, the issuance and sale of the Securities. The
Transaction Documents and the Company’s performance of its obligations
thereunder has been unanimously approved by the Company’s Board of Directors.

 

(d)       No Violation or Conflict. Assuming the representations and warranties
of the Subscribers in Section 2 are true and correct, neither the issuance and
sale of the Securities nor the performance of the Company’s obligations under
this Agreement and all other agreements entered into by the Company relating
thereto by the Company will violate, conflict with, result in a breach of, or
constitute a default (or an event which with the giving of notice or the lapse
of time or both would be reasonably likely to constitute a default) under (A)
the articles or certificate of incorporation, charter or bylaws of the Company,
(B) to the Company's knowledge, any decree, judgment, order, law, treaty, rule,
regulation or determination applicable to the Company of any court, governmental
agency or body, or arbitrator having jurisdiction over the Company or over the
properties or assets of the Company or any of its Affiliates, (C) the terms of
any bond, debenture, note or any other evidence of indebtedness, or any
agreement, stock option or other similar plan, indenture, lease, mortgage, deed
of trust or other instrument to which the Company or any of its Affiliates is a
party, by which the Company or any of its Affiliates is bound, or to which any
of the properties of the Company or any of its Affiliates is subject.

 

 

 

 4 

 

 

(e)       The Securities. The Securities upon issuance:

 

(i)         are, or will be, free and clear of any security interests, liens,
claims or other encumbrances, subject to restrictions upon transfer under the
1933 Act and any applicable state securities laws;

 

(ii)        have been, or will be, duly and validly authorized and issued, fully
paid and non-assessable;

 

(iii)       will not have been issued or sold in violation of any preemptive or
other similar rights of the holders of any securities of the Company;

 

(iv)       will not subject the holders thereof to personal liability by reason
of being such holders; and

 

(v)        assuming the representations warranties of the Subscribers as set
forth in Section 2 hereof are true and correct, will not result in a violation
of Section 5 under the 1933 Act.

 

(f)       No Integrated Offering. Neither the Company, nor any of its
Affiliates, nor any person acting on its or their behalf, has directly or
indirectly made any offers or sales of any security or solicited any offers to
buy any security under circumstances that would cause the offer of the
Securities pursuant to this Agreement to be integrated with prior offerings by
the Company for purposes of the 1933 Act or any applicable stockholder approval
provisions. Nor will the Company nor any of its Affiliates take any action or
steps that would cause the offer or issuance of the Securities to be integrated
with other offerings which would impair the exemptions relied upon in this
offering or the Company’s ability to timely comply with its obligations
hereunder. The Company will not conduct any offering other than the transactions
contemplated hereby that will be integrated with the offer or issuance of the
Securities, which would impair the exemptions relied upon in this offering or
the Company’s ability to timely comply with its obligations hereunder.

 

(g)       No General Solicitation. Neither the Company, nor any of its
Affiliates, nor to its knowledge, any person acting on its or their behalf, has
engaged in any form of general solicitation or general advertising (within the
meaning of Regulation D under the 1933 Act) in connection with the offer or sale
of the Securities.

 

(h)       Correctness of Representations. The Company represents that the
foregoing representations and warranties are true and correct as of the date
hereof in all material respects, and, unless the Company otherwise notifies the
Subscribers prior to the Closing Date, shall be true and correct in all material
respects as of the Closing Date.

 

4.       Indemnification.

 

(a)      The Company agrees to indemnify, hold harmless, reimburse and defend
the Subscribers, the Subscribers' officers, directors, agents, Affiliates,
control persons, and principal shareholders, against any claim, cost, expense,
liability, obligation, loss or damage (including reasonable legal fees) of any
nature, incurred by or imposed upon the Subscriber or any such person which
results, arises out of or is based upon (i) any material misrepresentation by
Company or breach of any warranty by Company in this Agreement or in any
Exhibits attached hereto, or other agreement delivered pursuant hereto; or (ii)
after any applicable notice and/or cure periods, any breach or default in
performance by the Company of any covenant or undertaking to be performed by the
Company hereunder, or any other agreement entered into by the Company and
Subscriber relating hereto.

 

(b)      Each Subscriber agrees to indemnify, hold harmless, reimburse and
defend the Company and each of the Company’s officers, directors, agents,
Affiliates, control persons against any claim, cost, expense, liability,
obligation, loss or damage (including reasonable legal fees) of any nature,
incurred by or imposed upon the Company or any such person which results, arises
out of or is based upon (i) any misrepresentation by such Subscriber in this
Agreement or in any Exhibits attached hereto, or other agreement delivered
pursuant hereto; or (ii) after any applicable notice and/or cure periods, any
breach or default in performance by such Subscriber of any covenant or
undertaking to be performed by such Subscriber hereunder, or any other agreement
entered into by the Company and Subscribers, relating hereto.

 

 

 

 5 

 

 

5.        Miscellaneous.

 

(a)      Notices. All notices, demands, requests, consents, approvals, and other
communications required or permitted hereunder shall be in writing and, unless
otherwise specified herein, shall be (i) personally served, (ii) deposited in
the mail, registered or certified, return receipt requested, postage prepaid,
(iii) delivered by reputable air courier service with charges prepaid, or (iv)
transmitted by hand delivery, telegram, or facsimile, addressed as set forth
below or to such other address as such party shall have specified most recently
by written notice. Any notice or other communication required or permitted to be
given hereunder shall be deemed effective (a) upon hand delivery or delivery by
facsimile, with accurate confirmation generated by the transmitting facsimile
machine, at the address or number designated below (if delivered on a business
day during normal business hours where such notice is to be received), or the
first business day following such delivery (if delivered other than on a
business day during normal business hours where such notice is to be received)
or (b) on the second business day following the date of mailing by express
courier service, fully prepaid, addressed to such address, or upon actual
receipt of such mailing, whichever shall first occur. The addresses for such
communications shall be: (i) if to the Company, to: Grom Social Enterprises,
Inc., 2060 NW Boca Raton Blvd. #6 Boca Raton, Florida 33431, (ii) if to the
Subscriber, to: the one or more addresses and telecopier numbers indicated on
the signature pages hereto.

 

(b)      Entire Agreement; Assignment. This Agreement and other documents
delivered in connection herewith represent the entire agreement between the
parties hereto with respect to the subject matter hereof and may be amended only
by a writing executed by both parties. Neither the Company nor the Subscribers
have relied on any representations not contained or referred to in this
Agreement and the documents delivered herewith. No right or obligation of the
Subscriber shall be assigned without prior notice to and the written consent of
the Company.

 

(c)      Counterparts/Execution. This Agreement may be executed in any number of
counterparts and by the different signatories hereto on separate counterparts,
each of which, when so executed, shall be deemed an original, but all such
counterparts shall constitute but one and the same instrument. The delivery of
an executed counterpart of this Agreement by electronic means, including by
facsimile or by "pdf" attachment to email, shall be deemed to be valid delivery
thereof binding upon all the parties hereto.

 

(d)      Law Governing this Agreement. This Agreement shall be governed by and
construed in accordance with the laws of the State of Florida without regard to
principles of conflicts of laws. Any action brought by either party against the
other concerning the transactions contemplated by this Agreement shall be
brought only in the state courts of Florida or in the federal courts located in
the state and county of Florida located in Palm Beach County, Florida. The
parties to this Agreement hereby irrevocably waive any objection to jurisdiction
and venue of any action instituted hereunder and shall not assert any defense
based on lack of jurisdiction or venue or based upon forum non conveniens. The
prevailing party shall be entitled to recover from the other party its
reasonable attorneys’ fees and costs. The parties executing this Agreement and
other agreements referred to herein or delivered in connection herewith on
behalf of the Subscriber agree to submit to the in personam jurisdiction of such
courts. In the event that any provision of this Agreement or any other agreement
delivered in connection herewith is invalid or unenforceable under any
applicable statute or rule of law, then such provision shall be deemed
inoperative to the extent that it may conflict therewith and shall be deemed
modified to conform with such statute or rule of law. Any such provision which
may prove invalid or unenforceable under any law shall not affect the validity
or enforceability of any other provision of any agreement. IN ANY ACTION, SUIT,
OR PROCEEDING IN ANY JURISDICTION BROUGHT BY ANY PARTY AGAINST ANY OTHER PARTY,
THE PARTIES EACH KNOWINGLY AND INTENTIONALLY, TO THE GREATEST EXTENT PERMITTED
BY APPLICABLE LAW, HEREBY ABSOLUTELY, UNCONDITIONALLY, IRREVOCABLY AND EXPRESSLY
WAIVES FOREVER TRIAL BY JURY.

 

(e)      Independent Nature of Subscribers.     The Company acknowledges that
the obligations of each Subscriber under the Transaction Documents are several
and not joint with the obligations of any other Subscriber, and no Subscriber
shall be responsible in any way for the performance of the obligations of any
other Subscriber under the Transaction Documents. The Company acknowledges that
each Subscriber has represented that the decision of each Subscriber to purchase
Securities has been made by such Subscriber independently of any other
Subscriber and independently of any information, materials, statements or
opinions as to the business, affairs, operations, assets, properties,
liabilities, results of operations, condition (financial or otherwise) or
prospects of the Company which may have been made or given by any other
Subscriber or by any agent or employee of any other Subscriber, and no
Subscriber or any of its agents or employees shall have any liability to any
Subscriber (or any other person) relating to or arising from any such
information, materials, statements or opinions.  The Company acknowledges that
nothing contained in any Transaction Document, and no action taken by any
Subscriber pursuant hereto or thereto shall be deemed to constitute the
Subscribers as a partnership, an association, a joint venture or any other kind
of entity, or create a presumption that the Subscribers are in any way acting in
concert or as a group with respect to such obligations or the transactions
contemplated by the Transaction Documents.  The Company acknowledges that each
Subscriber shall be entitled to independently protect and enforce its rights,
including without limitation, the rights arising out of the Transaction
Documents, and it shall not be necessary for any other Subscriber to be joined
as an additional party in any proceeding for such purpose.  The Company
acknowledges that it has elected to provide all Subscribers with the same terms
and Transaction Documents for the convenience of the Company and not because
Company was required or requested to do so by the Subscribers.  The Company
acknowledges that such procedure with respect to the Transaction Documents in no
way creates a presumption that the Subscribers are in any way acting in concert
or as a group with respect to the Transaction Documents or the transactions
contemplated thereby.

 

Remainder of Page Intentionally Omitted; Signature Pages to Follow

 

 

 

 6 

 

 

SIGNATURE PAGE TO SUBSCRIPTION AGREEMENT

 

 

 

Please acknowledge your acceptance of the foregoing Subscription Agreement by
signing and returning a copy to the Company; the Agreement shall become a
binding agreement between us upon the execution by the Company.

 

 

  GROM SOCIAL ENTERPRISES, INC.           By:___________________________________
  Name:   Title:       Dated: _________________, 2020

 

 

SUBSCRIBER PURCHASE PRICE AND AMOUNT OF SHARES OF PREFERED STOCK

Name of Subscriber:

 

__________________________________________________________

 

Address: __________________________________________________

 

_________________________________________________________

 

Fax No.: __________________________________________________

 

Email address: ________________________________________

 

 

Taxpayer ID# (if applicable): __________________________________

 

 

 

_________________________________________________________

(Signature)

By:

 

 

 

 

If an individual, provide copy of government issued identification, such as
passport or drivers' license

 

If an entity, provide copy of articles of incorporation, certificate of
formation or other documentation

 

 

 

 7