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Exhibit 99.1
SUBSCRIPTION AGREEMENT
Black Mountain Gold, Inc.
528 Fon du Lac Drive
East Peoria, Illinois 61611
Dear Sirs:
Concurrent with execution of this Agreement, the
undersigned (the "Purchaser") is purchasing ________________
shares of Common Stock of Black Mountain Gold, Inc. (the
"Company") at a price of $5.00 per Share (the "Subscription
Price").
Purchaser hereby confirms the subscription for and
purchase of said number of Shares and hereby agrees to pay
herewith the Subscription Price for such Shares.
MAKE CHECK PAYABLE TO: Black Mountain Gold, Inc.
Executed this _____ day of ________________, _______, at
_____________________ (Street Address), ___________________
(City), _________________ (State) ________ (Zip Code).
___________________________________
Signature of Purchaser
___________________________________
Printed Name of Purchaser
___________________________________
Social Security Number/
Tax I.D.
Number of Shares Purchased Total Subscription Price
__________________________ ________________________
Form of Payment: Cash _________________
Check# _________________
Other _________________
ACCEPTED THIS _____ DAY OF ________________, _______.
BLACK MOUNTAIN GOLD, INC.
BY: _______________________________
Title: ________________________
