Form of Subscription Agreement

EX-10.1 6 cleangoal-s1ex10z1.htm EXHIBIT 10.1

CLEANGOAL ENERGY, CORP.

 SUBSCRIPTION AGREEMENT

 

 

The Investor named below, by payment of the purchase price for such Common Shares, by the delivery of a check payable to CleanGoal Energy, Corp., hereby subscribes for the purchase of the number of Common Shares indicated below of CleanGoal Energy, Corp., at a purchase of $0.05 per Share as set forth in the Prospectus.

 

By such payment, the named Investor further acknowledges receipt of the Prospectus and the Subscription Agreement, the terms of which govern the investment in the Common Shares being subscribed for hereby.

 

A. INVESTMENT:               

 

(1) Number of Shares ___________________________

 

(2) Date of Investor's check _______________________

 

B. REGISTRATION:

 

(3) Registered owner: __________________________

 

Co-Owner: __________________________________

 

(4) Mailing address: ___________________________

 

City, State & zip: _________________________

 

(5) Residence Address (if different from above):

 

_________________________________         

 

(6) Birth Date: ______/______/______

 

(7) Employee or Affiliate: Yes ______ No ______

 

(8) Social Security: #: ______/______/______

 

U.S. Citizen [ ] Other [ ] __________________________

 

Co-Owner Social Security:

 

#: ______/______/______

 

U.S. Citizen [ ] Other [ ]

 

Corporate or Custodial:

 

Taxpayer ID #: ______/______/______

 

U.S. Citizen [ ] Other [ ] ___________________________

 

(9) Telephone (H) ( ) ______________________

 

(10) *email address:__________________________

 
 

*Please note that by providing your email address, you accept that all further communications between you and the Company shall be by email, unless otherwise required by law and/or the rules and regulations of any governing body of traded securities.

 

 C. OWNERSHIP

 

[ ] Individual Ownership                                           [ ] IRA or Keogh

 

[ ] Joint Tenants with Rights of Survivorship

 

[ ] Trust/Date Trust Established_______________

 

[ ] Pension/Trust (S.E.P.)

 

[ ] Tenants in Common                                             [ ] Tenants by the Entirety

 

[ ] Corporate Ownership                                           [ ] Partnership

 

[ ] Other_____________________

 

D. SIGNATURES

 

Registered Owner: _____________________________

 

 

Co-Owner: _____________________________

 

 

Print Name of Custodian or Trustee: _____________________________

 

 

Authorized Signature: _____________________________

 

 

Date: _____________________

 

 

Signature: ___________________________________

 

 

MAIL TO:   CleanGoal Energy, Corp.
    1717 N Bayshore Dr. #2831
    Miami FL, 33132

 

 

 

FOR CLEANGOAL ENERGY, CORP., OFFICE USE ONLY:

 

Date Received: ________________________________________________

 

Date Accepted/Rejected ________________________________________

 

Subscriber's Check Amount: _______________________

 

Check No. ___________________ Date Check ________________