Form S.a. 12 Escrow Agreement printable pdf download

Form S.a. 12 Escrow Agreement

S.A. 12 (1971)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

ESCROW AGREEMENT

As a condition of the registration approved by the Commission’s order dated

________________________________________

securities

issued

________________________________________ the owners of the hereinafter-described

securities hereby deliver the certificates or other evidence of said securities in escrow to

________________________________________ to hold subject to the provisions of Section

13.1-510(h) of the Code of Virginia.

The undersigned securityholders agree to deliver to the escrow agent any additional or

different securities received by them as a result of a stock dividend, stock split, merger or

consolidation and agree to refrain from voting any securities deposited hereinunder in favor of a

merger or consolidation. The undersigned issuer agrees to the conditions set forth above and

agrees to deliver such additional or different securities to the escrow agent. The undersigned

depository agrees not to release from escrow any of the securities except on order of the State

Corporation Commission.

President

Escrow agent

Title

Signature of stockholders

Number of Shares

Certificate Nos.

Form S.a. 12 Escrow Agreement