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Exhibit No. 10(i)(d)(i)
CAUTION: THIS FORM IS ONLY FOR USE BY RESIDENTS OF AZ, AR, FL, NC AND TX.
RESIDENTS OF AK, DC, HI, ID, MT, NE, NM, ND, RI, SD, TN, UT, VT, WA, AND WY ARE
NOT PERMITTED TO PURCHASE SHARES IN THIS OFFERING. RESIDENTS OF ALL OTHER STATES
MUST USE A DIFFERENT FORM.
INSTRUCTIONS TO
BROKER/DEALER INVESTOR SUBSCRIPTION AGREEMENT
FOR
FANZ ENTERPRISES, INC.
Persons interested in purchasing shares of Common Stock, $.01 par value
per share, ("Shares") of FanZ Enterprises, Inc. (the "Company") must :
1. FULLY complete and sign the attached Subscription Agreement (the
"Agreement");
PLEASE COMPETE THE ENTIRE FORM. INCOMPLETE FORMS WILL BE
RETURNED TO YOU.
2. Include a check made payable to "FIRSTAR BANK, N.A., ESCROW
ACCOUNT FOR FANZ ENTERPRISES, INC." (Please note the minimum
amount of $250.00.)
3. Send the completed and signed AGREEMENT AND CHECK to:
FanZ Enterprises, Inc.
5419 Cayman Drive
Carmel, IN 46033
Once the Company receives your executed Agreement and check, the check
will be sent to the escrow agent for processing and the Agreement will be sent
to our broker/dealer, Houlihan Smith & Company Inc., at 105 W. Madison, Suite
1500, Chicago, IL 60602. The broker/dealer will contact you to verify the
accuracy of your responses and to answer any question that you may have
regarding the Offering. If and when accepted, the Agreement shall constitute a
subscription for Shares of the Company. THE MINIMUM INVESTMENT IS $250.00 (25
SHARES).
The Company and the broker/dealer reserve the right to reject in its
entirety any subscription that is tendered or to allocate to any prospective
purchaser a smaller number of Shares than the prospective purchaser has
subscribed to purchase. In such event, the broker/dealer will return to you the
Agreement and the Company will return your payment (or a pro rata portion of
your payment, if subscription is rejected only in part), with interest if your
check or funds are deposited in the escrow account.
A copy of the accepted Agreement will be returned to you as your
receipt, and a stock certificate will be issued to you shortly thereafter.
PLEASE COMPLETE AND RETURN THE
ATTACHED PAGES WITH YOUR CHECK
NOTE: Before completing the attached subscription agreement, you should
carefully and completely read the Company's Prospectus. In making your
investment decision, you should rely only on the information in the
Company's Prospectus and not on any other information.
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BROKER/DEALER INVESTOR SUBSCRIPTION AGREEMENT
FOR
FANZ ENTERPRISES, INC.
I/we hereby irrevocably tender this Agreement for the purchase of
_________ Shares (25 SHARES MINIMUM) at $10.00 per Share. With this Agreement,
I/we tender payment in the amount of $_______ ($10.00 per Share; $250.00 MINIMUM
INVESTMENT) for the Shares subscribed.
In connection with this investment in the Company, I/we represent and
warrant as follows:
a. Prior to tendering payment for the Shares, I/we received the Company's
Prospectus dated ____________________________________ 2001.
b. I am/we are bona fide resident(s) of
______________________________________, __________________________________.
(State) (Country)
C. RESIDENTS OF AZ, AR, NC AND TX: I/we HAVE / DO NOT HAVE (please circle one)
either (i) an annual gross income of $65,000 or more and a minimum net
worth of $65,000 (excluding the value of automobiles, homes and home
furnishings) OR (ii) a minimum net worth of $150,000 (excluding the value
of automobiles, homes and home furnishings).(1)
Representations (MUST initial all categories):
____ (A) I meet AT LEAST one of the economic standards set forth in
Paragraph (c) above. (FL residents need not complete).
____ (B) I am purchasing the shares for my own account.
____ (C) I have received a copy of the Company's Prospectus.
____ (D) I understand that the shares being purchased are not liquid.
Form/Type of Ownership for Shares Being Purchased ( MUST check one):
___ Individual ___ Minor with adult custodian ___ Tenants-in-Common
___ Existing Partnership under the Uniform Gift ___ Joint Tenants
___ Corporation To Minors Act ___ Trust
For the person(s) who will be registered shareholder(s) (MUST FULLY COMPLETE):
Name of shareholder as you would like it to appear on stock certificate:
Name of shareholder as you would like it to appear on stock
certificate:________________________________________________
Name(s): __________________________________ Telephone:_______________________
Street Address:____________________________ Social Security or
Taxpayer ID No.:_________________
City:______________ State: ______ Zip:_____ Date of Birth:___________________
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(1) The state securities agencies of Arizona, Arkansas, Florida, North Carolina
and Texas require that residents may only purchase Shares through a
broker/dealer licensed with the state. Additionally, Arizona, Arkansas, North
Carolina and Texas have restricted the sale of these securities to only
residents of these states who meet the sophistication requirements of the North
American Securities Administrators Association. Residents of Arizona, Arkansas,
North Carolina and Texas who do not meet the income / net worth requirements in
section (c) above may not purchase Shares at this time.
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Signature: ___________________________________ Date:_______________________
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ACCEPTED BY: FANZ ENTERPRISES, INC.
By:____________________________ Title:________________________ Date:___________
Method of Payment: _____________________ Item No.: ___________________
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