MULTIBAND CORPORATION Renewable Unsecured Subordinated Note SubscriptionAgreement
Exhibit 4.4
MBND
MULTIBAND CORPORATION
Renewable Unsecured Subordinated Note Subscription Agreement
To purchase a Multiband Corporation renewable unsecured subordinated note(s), please complete both sides of this form and write a check made payable to Multiband Corporation. Mail this form, your check and any other documents requested below in the enclosed postage-prepaid business reply envelope. If you use your own envelope, please mail your investment to: Multiband Corporation, 5605 Green Circle Drive, Minnetonka, MN 55343. If you have any questions, please call ###-###-####.
NOTE PURCHASE AMOUNT (minimum principal amount $1,000 per note)
INTEREST PAYMENT SCHEDULE (Please select one for each note)
| Note Term | Principal Amount | Quarterly | Maturity | |||||||
| Three Month | $ | ¨ | ¨ | |||||||
| Six Month | $ | ¨ | ¨ | |||||||
| One Year | $ | ¨ | ¨ | |||||||
| Two Year | $ | ¨ | ¨ | |||||||
| Three Year | $ | ¨ | ¨ | |||||||
| Four Year | $ | ¨ | ¨ | |||||||
| Five Year | $ | ¨ | ¨ | |||||||
| Ten Year | $ | ¨ | ¨ | |||||||
| Total | $ | |||||||||
Form of Ownership (Pleas select one)
| £ | Individual Investor (with optional beneficiary) |
| £ | Joint Tenants with Right of Survivorship |
| £ | Custodian for a Minor |
| £ | Other IRA, SEP, 401(k), 403(b), Koegh, trust, corporation, partnership, etc. |
(Please include with this form a trust resolution or the appropriate corporation or partnership documents authorizing you to make this investment.)
Note Purchaser (please circle one)
Full Name of Individual Investor/First Joint Tenant/Minor/Entity/Administrator/Trustee
| / / | ||||
| First Name, Middle Name, Last Name | Social Security Number/Tax ID Number | Date of Birth (if applicable) |
Occupation:_________________ Age:____________
Full Name of Beneficiary/Second Joint Tenant/Custodian/Transfer on Death (please circle one if applicable)
| / / | ||||
| First Name, Middle Name, Last Name | Social Security Number/Tax ID Number | Date of Birth (not required for custodians |
| Primary Address (Original correspondence will be sent to this address.) | Secondary Address (Optional—copies of correspondence will be sent in this address.) |
| Individual Investor, IRA administrator, Trustee, Custodian, partnership, etc. | Beneficiary, IRA Owner, Joint Tenant, Partner, etc. |
| Address | Address |
| City | State | Zip | City | State | Zip |
| Daytime Phone (Include area code) | E-mail Address | Daytime Phone (include area code) | E-mail Address |
What is your approximate net worth, excluding the value of your primary residence, furnishings, and personal automobiles and the debt secured by these items (to the extent such debt does not exceed the value)? $______________________
What is your annual income? $_______________________
What percent of your net worth is currently invested in securities (stocks, bonds, notes, LLC or partnership interests) that are not traded on a stock exchange or NASDAQ? __________%
Suitability Standards Multiband Corporation has established minimum suitability standards for investors who reside in the following states: [________________________]. If you reside in one of these states, please see the notices on the reverse side for details.
Password When you call about your investment you may be asked to verify your identification by answering the following question:
What is your mother’s maiden name?_______________________
Direct Deposit Multiband Corporation will electronically deposit your principal and interest payments directly into the account listed in the Direct Deposit section on the reverse side of this form, please complete and sign the reverse side of this form for automatic deposit to either your checking or savings account.
SUBSTITUTE FORM W-9 CERTIFICATION Under penalties of perjury, I hereby declare and certify that: (i) the social security number or tax identification number listed above is correct (or I am waiting for a number to be issued to me); (ii) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (iii) I am a U.S. citizen or other U.S. person (as defined in the IRS Instructions to Form W-9).
Certification instructions. You must cross out item (ii) above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.
| SIGN HERE | SIGN HERE | |||
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| Signature of Individual Investor/First Joint Tenant/Custodian/Authorized Person | Date | Signature of Second Joint Tenant (if applicable) | Date |
ADDITIONAL CERTIFICATION Under penalties of perjury, I hereby declare and certify that: (i) I am a bona fide resident of the state listed in the primary mailing address; (ii) I have received and read the prospectus provided by Multiband Corporation, and understand the risks related to the notes and to the Company; (iii) neither Multiband Corporation, its affiliates or agents have recommended this investment to me or given me investment, legal or tax advice regarding the notes or the Company’s creditworthiness; (iv) I have independently determined that this investment is suitable for me without relying on such advice from Multiband Corporation, or its affiliates or agents; (v) the notes are unsecured and subordinate to all other Company indebtedness; (vi) the notes are illiquid due to significant transfer restrictions and the lack of a secondary market; (vii) the notes are obligations of Multiband Corporation, only they are not bank certificates of deposit and they are not guaranteed or insured by the FDIC or any other entity; (viii) I risk the loss of my entire principal amount and all accrued but unpaid interest when purchasing the notes and have the financial ability to withstand these losses; and (ix) I am purchasing the notes to fulfill my investment objective of earning current taxable interest income. I understand that my purchase offer is subject to the terms contained in the prospectus and to state securities regulations, may be rejected in whole or in part and will not become effective until accepted by Multiband Corporation.
| SIGN HERE | SIGN HERE | |||
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| Signature of Individual Investor/First Joint Tenant/Custodian/Authorized Person | Date | Signature of Second Joint Tenant (if applicable) | Date |
(Please complete reverse side)
| Office Use Only | MBND_________ | [ ]__________ | DATE__________ |
MBND
DIRECT DEPOSIT
Direct Deposit Account Information (please check one)
| £ | I currently receive or have received direct deposit payments for other notes purchased from Multiband Corporation. Please deposit all principal and interest payments for this new note into the same account. |
| £ | Please deposit my principal and interest payment into the same checking account that I am using to make this investment. The correct account information is listed on the enclosed check that I am using to purchase this note. |
| £ | Please deposit my principal and interest payments into the account listed below. (If this is a checking account, please attach a VOIDED check to the bottom of this form. If this is a savings account, please confirm the bank routing number and the account number with your financial institution.) |
Account Owner Name(s)
__________________________________________ £ Checking £ Savings £ Other
| Bank Routing Number (9 digits) | Bank Name Branch Location | ||||||||||
Some financial institutions (e.g., brokerage firms, custodians, mutual savings banks, credit unions, money market funds, etc.) also require “for further credit” information to correctly identify direct deposit accounts. If your financial institution requires this additional information, please list it below. If you are unsure if this additional information is required, please call your financial institution.
For further credit:________________________
Direct Deposit Authorization
As the investor of record and authorized signatory of the account listed above, I hereby authorize Multiband Corporation, its affiliates, or its agents (collectively referred to hereinafter as “MBND”) to deposit interest and principal payments owed to me, by initiating credit entries in the account to my financial institution listed on this form. Further, I authorize my financial institution to accept and to credit any credit entries initiated by MBND to the listed account. In the event of an erroneous credit entry, I also authorize MBND to debit the account for an amount not to exceed the original amount of the erroneous credit.
This authorization is to remain in full force and effect until MBND and my financial institution have received written notice from me of its termination in such time and in such manner as to afford MBND and my financial institution reasonable opportunity to act on it. In the event the listed account is closed, I will promptly notify MBND of an alternate account into which payments can be made.
| SIGN HERE | ||
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| Authorized Signature | Date |
Mail to:
Multiband Corporation
5605 Green Circle Drive
Minnetonka, MN 55343
ATTACH VOIDED CHECK HERE
