Exhibit 99.1
PHASE I AND PHASE II MARCO COMMUNITY BANCORP, INC.
STOCK ORDER FORM
& CERTIFICATION
Note: Please read the Order Form Guide and Instructions contained in the
Prospectus
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Deadline: The offering began __________________. A condition of the offering is
that the minimum offering (sale of 800,000 units, each unit consisting of one
share of common stock and one warrant entitling the holder thereof to purchase
one quarter of one share of additional common stock) must be completed on or
before ___________________, unless extended by the Board of Directors for up to
an additional 60 days, or the offering will be terminated. If the minimum
offering is consummated, the first two phases will continue until a total of
1,000,000 units have been sold, or until 5:00 p.m., on ________, 2003, whichever
occurs first, unless terminated by us beforehand.
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Number of Units
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(1) Number of Units Price Per Unit (2) Total Amount Due
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| | x $9.00 = | $ |
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The minimum number of units that may be subscribed for is 100. Except for our
directors and employees, the maximum any individual and their related party may
subscribe for in the offering is 25,000 units.
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Method of Payment
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(3) Enclosed is a check, bank draft or money order payable to INDEPENDENT
BANKERS' BANK OF FLORIDA FOR MARCO COMMUNITY BANCORP, INC. for
$______________.
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Broker Dealer Name and Address
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(4) If purchased through a broker/dealer, please list the name, address, and
phone number in the space provided.
Company Name:_____________________ City:_______________________________
Broker Name:______________________ State:______________ Zip Code:_______
Street Address:___________________ Phone Number:__________________________
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Stock Registration ONE OWNERSHIP PER ORDER FORM
(5) Form of stock ownership
|_| Individual |_| Corporation |_| Partnership
|_| Joint Tenants |_| *Uniform Transfer or Gift to Minors |_| IRA (Custodian Name and Signature Required)
|_| Tenants in Common |_| Tenant by the Entireties |_| Fiduciary/Trust (Under Agreement Dated ________)
(husband and wife only)
* Minor's Social Security Number Required
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Name | Social Security or Tax I.D.
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Name | Daytime Telephone
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Street Address | Evening Telephone
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City State Zip Code | State-of-Residence
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OFFICE USE: Date Received ________ Check #________ Amount $_________
Order #________ Category ________ Initials __________
NASD Affiliation (This section only applies to those individuals who meet the
delineated criteria)
|_| Check here if you are a member of the National Association of Securities
Dealers, Inc. ("NASD"), a person associated with an NASD member, a member of the
immediate family of any such person to whose support such person contributes,
directly or indirectly, or the holder of an account in which an NASD member or
person associated with an NASD member has a beneficial interest. To comply with
conditions under which an exemption from the NASD's Interpretation with Respect
to Free-Riding and Withholding is available, you agree, if you have checked the
NASD affiliation box: (1) not to sell, transfer or hypothecate the units
subscribed for herein for a period of three months following the issuance, and
(2) to report this subscription in writing to the applicable NASD member within
one day of the payment therefor.
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Acknowledgments
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By signing below:
1. I acknowledge receipt of the Prospectus dated_____________, 2003. I
understand that I may not change or revoke my order once it is received
by Marco Community Bancorp, Inc. I also certify that this order is for my
account and not for resale.
2. I certify that:
(i) the social security number or taxpayer identification number given
herein is correct; and (ii) I am not subject to backup withholding.
If you have been notified by the Internal Revenue Service that you are
subject to backup withholding because of under-reporting interest or
dividends on your tax return, you must cross out Item (ii) above.
3. I acknowledge that I have not waived any rights under the Securities Act
of 1933 and the Securities Exchange Act of 1934.
4. I acknowledge that Marco Community Bancorp, Inc. has the right to accept
or reject this Stock Order Form in whole or in part.
5. I certify that I am a bona fide resident of:
o Marco Island, Goodland or Isle of Capri, Florida or the
subdivisions in unincorporated Collier County, Florida known as
Fiddlers Creek or located on Mainsail Drive; or
o Another part of Florida.
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THIS FORM MUST BE SIGNED AND DATED. THIS ORDER IS NOT VALID IF THE ORDER FORM IS
NOT SIGNED. YOUR ORDER WILL BE FILLED IN ACCORDANCE WITH THE PROVISIONS OF THE
PROSPECTUS.
When purchasing as a custodian, corporate officer, etc.; include your full
title.
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Signature Title (if applicable) Date
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1.
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2.
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3.
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THE UNITS OFFERED HEREBY ARE NOT DEPOSITS AND ARE NOT INSURED OR GUARANTEED BY
THE FEDERAL DEPOSIT INSURANCE CORPORATION OR ANY OTHER GOVERNMENTAL AGENCY.
RETURN THIS FORM TO: Independent Bankers' Bank of Florida
Post Office Box 958423
Lake Mary, Florida 32795-8423
Marco Community Bancorp, Inc.
ORDER FORM GUIDE AND INSTRUCTIONS
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Instructions
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Items 1 and 2 - Fill in the number of units that you wish to purchase and the
total payment due. The amount due is determined by multiplying the number of
units by the purchase price of $9.00 per unit. The minimum purchase is 100 units
and the maximum purchase is 25,000 units, unless you are one of our employees or
directors. In addition, all person's purchases are aggregated, together with
associates of, and persons acting in concert with such person, to determine the
maximum permissible purchase.
Marco Community Bancorp, Inc. ("MCBI") has reserved the right to reject any
subscription received in the offering, in whole or in part.
Item 3 - Payment for units or shares may be made by check, bank draft or money
order made payable to "INDEPENDENT BANKERS' BANK OF FLORIDA FOR MARCO COMMUNITY
BANCORP, INC." PLEASE DO NOT MAIL CASH. Your funds will be returned promptly
with interest if the offering is terminated.
Item 4 - If purchasing through a broker/dealer please list the name, address and
phone number in this box.
Item 5 - The stock transfer industry has developed a uniform system of
shareholder registrations that we will use in the issuance of MCBI's common
stock and warrants. Print the name(s) in which you want the shares and warrants
registered and the mailing address of the shareholder. Include the first name,
middle initial and last name of the shareholder. Avoid the use of two initials.
Please omit words that do not affect ownership rights, such as "Mrs.," "Mr.,"
"Dr.," "special account," etc.
PLEASE SEE YOUR LEGAL OR FINANCIAL ADVISOR IF YOU ARE UNSURE ABOUT THE CORRECT
REGISTRATION OF YOUR STOCK.
Individual - The shares and warrants are to be registered in an individual's
name only. You may not list beneficiaries for this ownership.
Tenants in Common - Tenants in common may include two or more owners. When
shares or warrants are held by tenants in common, upon the death of one
co-tenant, ownership of the shares or warrants will be held by the surviving
co-tenant(s) and by the heirs of the deceased co-tenant. All parties must agree
to the transfer or sale of shares or warrants held by tenants in common. You may
not list beneficiaries for this ownership.
Individual Retirement Account - Individual Retirement Account ("IRA") holders
may make unit or share purchases from their IRA accounts through a pre-arranged
"trustee-to-trustee" transfer. Shares and warrants may only be held in a
self-directed IRA. MCBI will not offer a self-directed IRA. The Subscription
Agreement must be completed and executed by the IRA Custodian. Please contact
MCBI if you have any questions about your IRA account.
Uniform Transfer or Gift to Minors - For residents of many states, shares and
warrants may be held in the name of a custodian for the benefit of a minor under
the Uniform Transfers to Minors Act. For residents in other states, shares or
warrants may be held in a similar type of ownership under the Uniform Gift to
Minors Act of the individual states. For either type of ownership, the minor is
the actual owner of the shares or warrants with the adult custodian being
responsible for the investment until the child reaches legal age.
On the first line, print the first name, middle initial and last name of the
custodian, with the abbreviation "CUST" and "Unif Tran Min Act" or "Unif Gift
Min Act" after the name. Print the first name, middle initial and last name of
the minor on the second "NAME" line. Standard U.S. Postal Service state
abbreviations should be used to describe the appropriate state. For example,
shares or warrants held by John Doe as custodian for Susan Doe under the Florida
Transfer to Minors Act will be abbreviated John Doe, CUST Susan Doe Unif Tran
Min Act. FL. Use the minor's Social Security Number. Only one custodian and one
minor may be designated.
Joint Tenants - Joint Tenants with right of survivorship identifies two or more
owners. When shares or warrants are held by joint tenants with rights of
survivorship, ownership automatically passes to the surviving joint tenant(s)
upon the death of any joint tenant. You may not list beneficiaries for this
ownership.
Tenants by the Entireties - Husband and wife only. Essentially the same as Joint
Tenants.
Corporation/Partnership - Corporations/Partnerships may purchase units or
shares. Please provide the Corporation's/ Partnership's legal name and Tax I.D.
Fiduciary/Trust - Generally, fiduciary relationships (such as trusts, estates,
guardianships, etc.) are established under a form of trust agreement or pursuant
to a court order. Without a legal document establishing a fiduciary
relationship, your shares or warrants may not be registered in a fiduciary
capacity.
On the first "NAME" line, print the first name, middle initial and last name of
the fiduciary if the fiduciary is an individual. If the fiduciary is a
corporation, list the corporate title on the first "NAME" line. Following the
name, print the fiduciary "title" such as trustee, executor, personal
representative, etc.
On the second "NAME" line, print either the name of the maker, donor or testator
OR the name of the beneficiary. Following the name, indicate the type of legal
document establishing the fiduciary relationship (agreement, court order, etc.).
In the blank after "Under Agreement Dated," fill in the date of the document
governing the relationship. The date of the document need not be provided for a
trust created by a will.
An example of fiduciary ownership of stock or warrants in the case of a trust
is: "John D. Smith, Trustee for Thomas A. Smith Trust Under Agreement dated June
9, 1987."
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Definition of Associate
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A person's associates consist of the following: (1) any corporation or other
organization (other than MCBI) of which such person is a director, officer or
partner or is directly or indirectly the beneficial owner of 10% or more of any
class of equity securities; (2) any trust or other estate in which such person
has a substantial beneficial interest or as to which such person serves as
trustee or in a similar fiduciary capacity, provided, however, that such term
shall not include any tax-qualified employee stock benefit plan of MCBI in which
such person has a substantial beneficial interest or serves as a trustee or in a
similar fiduciary capacity; and (3) any spouse of such person, or any relative
of such person, who either has the same home as such person or who is a director
or officer of MCBI.