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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 (MUST INITIAL ALL CATEGORIES):
____ (A) I am/we are bona fide resident(s) of , .
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(State) (Country)
____ (B) I am/we are purchasing the shares for my/our own account.
____ (C) I/we have received a copy of the Company's Prospectus, dated
_____________, 2001.
____ (D) I/we understand that the shares being purchased are not liquid.
____ (E) RESIDENTS OF AZ, AR, NC AND TX ONLY: I/we have either (i) an
annual gross income of $65,000 or more and a minimum net worth of
$65,000 OR (ii) a minimum net worth of $150,000. (All computations of
net worth must exclude the value of the investor's principal
residence, its furnishings and personal automobile(s). All other
assets should be valued at their fair market value).
PLEASE NOTE: The securities agencies of the following states require that
residents of these states must meet the investor suitability standards listed
below prior to being permitted to invest in the Company's Stock.
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ALABAMA, NEW JERSEY & VIRGINIA Residents must have either (i) an individual
income of $200,000 or more in each of the
two most recent years or joint income with
their spouse in excess of $300,000 in each
of those years and reasonably expect to
reach the same income level in the current
year OR (ii) an individual net worth or
joint net worth with their spouse at the
time of subscription of $1,000,000. (All
computations of net worth must exclude the
value of the investor's principal residence,
its furnishings and personal automobile(s).
All other assets should be valued at their
fair market value.)
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OHIO In order to subscribe for more than the
minimum number of 25 Shares, residents must
have either (i) an individual or joint
annual income with their spouse in excess of
$65,000 and an individual or joint net worth
with their spouse of $65,000 (including the
value of homes, home furnishings and
automobiles) OR (ii) an individual or joint
net worth with their spouse of $500,000
(including the value of homes, home
furnishings and automobiles).
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ARIZONA, ARKANSAS, CALIFORNIA, Residents must have either (i) an annual
CONNECTICUT, DELAWARE, INDIANA, gross income of $65,000 or more and a
IOWA, KANSAS, KENTUCKY, MAINE, minimum net worth of $65,000 OR (ii) a
MARYLAND, MASSACHUSETTS, minimum net worth of $150,000. (All
MICHIGAN, MINNESOTA, MISSISSIPPI, computations of net worth must exclude the
MISSOURI, NEVADA, NEW HAMPSHIRE, value of the investor's principal residence,
NORTH CAROLINA, OKLAHOMA, OREGON, its furnishings and personal automobile(s).
PENNSYLVANIA, SOUTH CAROLINA, All other assets should be valued at their
TEXAS, WEST VIRGINIA & WISCONSIN fair market value.)
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PLEASE CONTINUE ON THE NEXT PAGE
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Form/Type of Ownership for Shares Being Purchased ( MUST check one):
___ Individual
___ Existing Partnership
___ Corporation
___ Minor with adult custodian
under the Uniform Gift
To Minors Act
___ Tenants-in-Common
___ Joint Tenants
___ 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:
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Name(s): Telephone:
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Street Address: Social Security or
------------------------- Taxpayer ID No.:
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City: State: Zip: Date of Birth:
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Signature: Date:
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ACCEPTED BY: FANZ ENTERPRISES, INC.
By: Title: Date:
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Method of Payment: Item No.:
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