AGREEMENT TO PURCHASE
UNDER SECURITIES AND EXCHANGE COMMISSION RULE 15G, IT IS UNLAWFUL FOR US TO
EFFECT THE SALE OF THE DESIGNATED SECURITIES IDENTIFIED BELOW UNLESS WE
HAVE RECEIVED, PRIOR TO THE TRANSACTION, A WRITTEN AGREEMENT TO THE
TRANSACTION.
By signing below, you are agreeing to the purchase of the shares identified below at a price that will be confirmed to you for your agreement by your account executive prior to execution of the transaction.
DESIGNATED SECURITIES:
Name of Issuer_________________________________________________________
Type of Security (common stock, units, warrants, etc.) __________________________
Number of Shares__________________
Signature of Customer(s) ______________________________Date:_______________
Printed Name:______________________________________
Signature of Customer(s) ______________________________Date:_______________
Printed Name:______________________________________
Signature of Registered Representative:______________________________Date:___________