STOCK ORDER FORM NEOSURG TECHNOLOGIES, INC.
17300 El Camino Real, Suite 110
Houston, Texas 77058
Note: Please read the Stock Order Form Guide and Instructions attached to this
form before completion.
--------------------------------------------------------------------------------
DEADLINE
--------------------------------------------------------------------------------
The Offering ends at 4:00 p.m., _____ Texas time, on _______ _____, 2000. Your
Stock Order Form and Certification form, properly executed and with the correct
payment, must be received at the address on the bottom of this form by this
deadline or it may be considered void. Faxes or copies of these Forms will not
be accepted.
--------------------------------------------------------------------------------
NUMBER OF SHARES
--------------------------------------------------------------------------------
(1) Number of Shares Price Per Share
(2) Total Amount Due
------------- -------------
| | |$ |
------------- X $6.75 = -------------
(minimum 300)
The minimum number of shares that may be subscribed for is 300 and the maximum
individual purchase is _____ shares in the Offering.
--------------------------------------------------------------------------------
Method of Payment Purchaser Information
--------------------------------------------------------------------------------
(3) ___ Enclosed is a check, bank draft or money (4) ___ Check here
if you are a director, officer or employee of NeoSurg Technologies,
Inc. or order payable to NeoSurg Technologies, Inc. a member of such
person's immediate family.
for $_______________ (or cash if
presented in person)
Payments will be deposited in an Escrow Account with First Community Bank, N.A.,
Houston, Texas. Payment by check, cash, money order or withdrawals from
non-certificate accounts will earn interest in the Escrow Account until the
stock offering closes.
<TABLE>
<CAPTION>
--------------------------------------------------------------------------------------------------------------------------
STOCK REGISTRATION
--------------------------------------------------------------------------------------------------------------------------
<S> <C> <C>
(5) Form of stock ownership
____ Individual ____ Uniform Transfer to Minors ____ Partnership
____ Joint Tenants (WROS) ____ Uniform Gift to Minors ____ Individual Retirement Account
____ Tenants in Common ____ Corporation ____ Fiduciary/ Trust (Under Agreement Dated__________)
(6) Name (Please Print Clearly)____________________________ Social Security or Tax. I.D. ________________________
Name __________________________________________________ Daytime Telephone ___________________________________
Street Address ________________________________________ Evening Telephone ___________________________________
City _______________ State ______ Zip Code ____________ County of Residence _________________________________
</TABLE>
--------------------------------------------------------------------------------
NASD AFFILIATION (This section only applies to those individuals who meet the
delineated criteria.)
--------------------------------------------------------------------------------
_____ check here if you are a member of the National Association of
Securities Dealers, Inc. ("NASD"), a person associated with an NASD member, a
member of the immediate family of any such person to whose support such person
contributes, directly or indirectly, or the holder of an account in which an
NASD member or person associated with an NASD member has a beneficial interest.
To comply with conditions under which an exemption from the NASD's
Interpretation With Respect to Free-Riding and Withholding is available, you
agree, if you have checked the NASD affiliation box: (i) not to sell, transfer
or hypothecate the stock for a period of 150 days following the issuance, and
(ii) to report this subscription in writing to the applicable NASD member within
one day of the payment therefor.
--------------------------------------------------------------------------------
ACKNOWLEDGEMENT
--------------------------------------------------------------------------------
By signing below, I acknowledge receipt of the Prospectus dated
________________, 2000 and that I have reviewed the provisions therein and
understand that I may not change or revoke my order once it is received by
NeoSurg Technologies, Inc. I certify that this stock order is for my account
only and there is no agreement or understanding regarding any further sale or
transfer of these shares.
Under penalties of perjury, I further certify that: (1) the social security
number or taxpayer identification number given above is correct; and (2) I am
not subject to backup withholding. You must cross out this item, (2) above, if
you have been notified by the Internal Revenue Service that you are subject to
backup withholding because of underreporting interest or dividends on your tax
return.
--------------------------------------------------------------------------------
SIGNATURE
--------------------------------------------------------------------------------
Sign and date the form. This order is not valid if the Stock Order Form and
Certification Form are not both signed and properly completed. When purchasing
as a custodian, include your full title. An additional signature is required
only when payment is by withdrawal from an account that requires more than one
signature to withdraw funds.
YOUR ORDER WILL BE FILLED IN ACCORDANCE WITH THE PROVISIONS OF THE PROSPECTUS.
THIS ORDER IS NOT VALID IF NOT SIGNED. If you need help completing this Form,
you may call the Stock Sales Center at (___) __________.
--------------------------------------------------------------------------------
Signature Title (if applicable) Date
--------------------------------------------------------------------------------
Signature Title (if applicable) Date
Broker Assisted Orders-Refer to Prospectus.
--------------------------------------------------------------------------------
A.E. Name R. R. Number B/D Name
--------------------------------------------------------------------------------
B/D Mailing Address/City/State/Zip Code Telephone Number
FOR OFFICE USE ONLY
STOCK SALES CENTER
Date Rec'd ____/___/___ Order # _________ Batch # ____
/Check # ____________ Category _________________
Amount $ ____________ Initials _________________ (____) ____-______
<PAGE>
CERTIFICATION FORM
------------------
(This Certification Form Must Be Signed in Addition to the Stock Order Form)
SUBSCRIBERS WHO ARE RESIDENTS OF ALABAMA, ARIZONA, ARKANSAS, CALIFORNIA,
INDIANA, KANSAS, KENTUCKY, MASSACHUSETTS, MICHIGAN, MISSOURI, NEVADA, OHIO,
OKLAHOMA, OREGON, PENNSYLVANIA, TEXAS, VIRGINIA, WASHINGTON AND WEST VIRGINIA
MUST MEET ONE OF THE FOLLOWING SUITABILITY REQUIREMENTS:
CHECK ONE:
-----------
______ I represent to NeoSurg Technologies, Inc. ("NeoSurg") and Investors
Trading Corp. d/b/a Oxford Financial Group ("Oxford") that I have an annual
gross income of at least $65,000 and a minimum net worth of $65,000,
exclusive of home, home furnishings and automobiles; or
______ I represent to NeoSurg and Oxford that I have a minimum net worth of
$150,000, exclusive of home, home furnishings and automobiles.
Date: ________________ ______________________________
Subscriber
Date: ________________ ______________________________
Subscriber
NEW JERSEY INDIVIDUAL SUBSCRIBERS MUST BE AN "ACCREDITED INVESTOR" AS DEFINED
UNDER RULE 501 OF REGULATION D UNDER THE SECURITIES ACT OF 1933.
CHECK ONE:
-----------
________ I represent to NeoSurg and Oxford that I my individual net worth
or joint net worth with my spouse, at the time of my purchase exceeds
$1,000,000; or
________ I represent to NeoSurg and Oxford that in each of 1998 and 1999 my
individual income was in excess of $200,000, or my joint income with my spouse
was in excess of $300,000, and I reasonably expect to reach the same income
level in the current year.
Date: ________________ ______________________________
Subscriber
Date: ________________ ______________________________
Subscriber
<PAGE>
