from SB-2/A
1 page
Exhibit 1.1 Global Health Trax, Inc. Subscription Agreement the Investor Named Below, by Payment of the Purchase Price for Such Common Shares, by the Delivery of a Check Payable to Global Health Trax, Inc., Hereby Subscribes for the Purchase of the Number of Common Shares Indicated Below at a Purchase of $1.25 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) Total Contribution ($1.25/Share) $ 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) ( ) 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 <page> D. Signatures: By Signing Below, I/We Represent That I/We Meet the Suitability Standards Set Forth in the Prospectus. Registered Owner: Co-Owner: Print Name of Custodian or Trustee: Authorized Signature: Date: Signature: - For Office Use Only: Date Received: Date Accepted/Rejected Subscriber's Check Amount: Check No. Date Check Deposited Mr #
