BURRIS ENERGY, LLC - PHASE 1

    SUBSCRIPTION AGREEMENT - SERIES A


    I. INTRODUCTION

    The information provided here and on any attached supporting documentation will be protected for your privacy.

    The company will not disseminate any information or documents unless and until, by your signature on the subscription agreement, you authorize the release of same, and then, only for purposes of this purchase.

    Upon any purchase, the information and documents will be deleted, for your privacy.


    II. INFORMATION OF THE BUYER OR AGENT

    A . Please check the appropriate box section here:

    Name to appear on shares certificate


    B. My current, verifiable, actual information is :

    Name
    Address Line 1
    Address Line 2
    City
    State
    Zipcode
    Phone Number
    eMail Address


    III. AMOUNT OF THE PURCHASE FOR THIS CONTRACT

    I am requesting that the following U. S. dollar amount be placed on the subscription agreement as the amount of purchase for this contract
    $

    Click here to download the Series A Term Sheet and the Terms & Conditions documents





    BURRIS ENERGY, LLC - PHASE 1

    SUBSCRIPTION AGREEMENT - SERIES A


    I. INTRODUCTION

    The attached supporting documentation will be protected for your privacy.

    The company will not disseminate any information or documents unless and until, by your signature on the subscription agreement, you authorize the release of same, and then, only for purposes of this purchase.

    Upon any purchase, the information and documents will be deleted, for your privacy.


    II. DOCUMENT REQUEST OF THE BUYER: a copy of a current State issued identification card.

    Please describe the document :

    Please upload a copy of the card in pdf format below.


    III. DOCUMENT REQUEST OF THE AGENT OF THE BUYER: please check one of the following:
    a copy of a current State issued identification card.a copy of a registered broker-dealer license.a copy of an investment adviser authorization, registered with the S.E.C.a copy of a bar membership card of a licensed attorney who is in good standing under the laws of the jurisdictions in which he or she is admitted to practice law.a copy of a certified public accountant (CPA) membership card, who is duly registered and in good standing under the laws of the place of his or her residence or principal office

    Please upload your documentation in pdf format here:


    BY CONTINUING with this registration, I understand that any information that I provide is password protected, and that I may instruct the seller to delete my information at any time.

    I, further, verify here that, by signing any subscription agreement, I am signing same as a bona fide buyer, that the information provided is true, correct and current, that in making the purchase, I am doing so as a private purchase, and that I am not a member of any regulatory or law enforcement agency.

    I, further, acknowledge that the seller may have other offering programs, which may include public offerings, but that any offerings must run parallel and not in conjunction with any other offering. Thus, I acknowledge that this purchase is wholly unrelated to any other offering programs that the seller may have in place.