Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 79 contracts
Samples: Underwriting Agreement (High Roller Technologies, Inc.), Underwriting Agreement (Oragenics Inc), Underwriting Agreement (Red Cat Holdings, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 62 contracts
Samples: Meridian Waste Solutions, Inc., Meridian Waste Solutions, Inc., Meridian Waste Solutions, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 36 contracts
Samples: Underwriting Agreement (Lirum Therapeutics, Inc.), Underwriting Agreement (Lirum Therapeutics, Inc.), Placement Agency Agreement (Biovie Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 17 contracts
Samples: Underwriting Agreement (iSpecimen Inc.), Underwriting Agreement (Harbor Custom Development, Inc.), Creatd, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 13 contracts
Samples: Underwriting Agreement (Sidus Space Inc.), Underwriting Agreement (Sidus Space Inc.), Underwriting Agreement (Strong Global Entertainment, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Underwriting Agreement (Innovation Beverage Group LTD), Underwriting Agreement (Tharimmune, Inc.), Warrant Agreement (Tharimmune, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Underwriting Agreement (EzFill Holdings Inc), Underwriting Agreement (OMNIQ Corp.), Underwriting Agreement (BriaCell Therapeutics Corp.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant ADSs.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Name: (Please Print) Address: (Please Print) Dated: _______________ __, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Securities Purchase Agreement (Nano Dimension Ltd.), Securities Purchase Agreement (Nano Dimension Ltd.), Securities Purchase Agreement (Nano Dimension Ltd.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 11 contracts
Samples: Securities Purchase Agreement (Generex Biotechnology Corp), Securities Purchase Agreement (Generex Biotechnology Corp), Pacific Gold Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: ________________________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 10 contracts
Samples: Kingold Jewelry, Inc., Bioxytran, Inc, Bioxytran, Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantpurchase Warrant ADSs.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Name: (Please Print) Address: (Please Print) Dated: _______________ __, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 8 contracts
Samples: Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [amended. SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 7 contracts
Samples: Common Stock Purchase Warrant (OverNear, Inc.), Preferred Stock Purchase Warrant (OverNear, Inc.), OverNear, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 6 contracts
Samples: Underwriting Agreement (Azitra, Inc.), Underwriting Agreement (Alta Global Group LTD), Underwriting Agreement (Azitra Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: __________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 6 contracts
Samples: Underwriting Agreement (Forza X1, Inc.), Underwriting Agreement (EzFill Holdings Inc), Underwriting Agreement (EzFill Holdings Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 5 contracts
Samples: Underwriting Agreement (Rise Oil & Gas, Inc.), Underwriting Agreement (Azitra Inc), Perfect Moment Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D D, promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ANNEX B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, ___________ Holder’s Signature: _______________________________ Holder’s Address: _______________________________ _______________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Common Stock Purchase Warrant (Theralink Technologies, Inc.), Enochian Biosciences Inc, Common Stock Purchase Warrant (Amesite Inc.)
Accredited Investor. If Unless the Warrant is being exercised via cash exerciseexercise pursuant to a cashless exercise in accordance with Section 2(c) of the Warrant or unless the Warrant Shares are registered under the Securities Act of 1933, as amended (the "Securities Act"), the undersigned represents it is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended Act. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Zoom Technologies Inc, Zoom Technologies Inc, Zoom Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. Name of Investing EntityHolder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityHolder: ____________________________________________ Name of Authorized Signatory: _______________Signatory (if Holder is an entity): ____________________________________________ Title of Authorized Signatory: __________________Signatory (if Holder is an entity): __________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ _________________, whose address is _______________________________________________________________. _______________ _______________________________________________________________ _______________. Dated: ______________, _______ Holder’s Name: _________________________________________ Holder’s Signature: _________________________________________ Holder’s Address: _________________________________________ _________________________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Assignment Form (Echo Therapeutics, Inc.), Tagalder Global Investment, Inc., Tagalder Global Investment, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 4 contracts
Samples: MeeMee Media Inc., Aurelio Resource Corp, Wifimed Holdings Company, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Placement Agency Agreement (Akers Biosciences Inc), Akers Biosciences Inc, Toughbuilt Industries, Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________________________________________ Name of Authorized Signatory: ________________________________________________________________________________________________ Title of Authorized Signatory: _________________________________________________________________________________________________ Date: ____________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Virios Therapeutics, LLC), Underwriting Agreement (Catasys, Inc.), Underwriting Agreement (Catasys, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________ Date: _____________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Marpai, Inc.), Odd Burger Corp, Nuvectis Pharma, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Snow Lake Resources Ltd.), Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ . Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 3 contracts
Samples: Underwriting Agreement (MR2 Group, Inc.), Underwriting Agreement (MR2 Group, Inc.), MR2 Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: _______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: Red Metal Resources, Ltd., Digital Angel Corp, Digital Angel Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 3 contracts
Samples: ONCOSEC MEDICAL Inc, Lilis Energy, Inc., Celsion CORP
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: MetaStat, Inc., Photovoltaic Solar Cells, Inc., Peoples Liberation Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: Exchange Agreement (Protea Biosciences Group, Inc.), Protea Biosciences Group, Inc., Protea Biosciences Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________ Name of Authorized Signatory: _________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________ Date: ______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: www.sec.gov, H & H Imports, Inc., H & H Imports, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares Common Stock Warrants of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: GeoVax Labs, Inc., Vuzix Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________:_______________________ Name of Authorized Signatory: ___________:________________________________________________ Title of Authorized Signatory: _____________:_______________________________________________ Date: ________:________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: _________________________________________________
Appears in 2 contracts
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: :________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: SIMPLICITY ESPORTS & GAMING Co, SIMPLICITY ESPORTS & GAMING Co
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Accredited Investor. If the Underwriter’s Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Underwriter’s Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Harbor Custom Development, Inc.), Underwriting Agreement (Harbor Custom Development, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this executethis form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Proteonomix, Inc., Proteonomix, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: CytoMed Therapeutics LTD, Vivakor, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Common Stock Purchase Warrant (As Seen on TV, Inc.), As Seen on TV, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Parkview Group Inc, Cord Blood America, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is EXHIBIT B ASSIGNMENT FORM (To assign the foregoing Warrant, execute this form and supply required information. Do not use this form to purchase Warrant ADSs.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to Name: ______________________________________ (Please Print) Address: _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Midatech Pharma PLC, Midatech Pharma PLC
Accredited Investor. If the Warrant is being exercised via cash exerciseexercise and no registration statement covering the issuance of the Warrant Shares is effective, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Sushi Ginza Onodera, Inc., Silynxcom Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 2 contracts
Samples: Polyrizon Ltd., Inspira Technologies OXY B.H.N. LTD
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: _______________________ Date: __________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Rennova Health, Inc.), Underwriting Agreement (Rennova Health, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (MAIA Biotechnology, Inc.), Underwriting Agreement (MAIA Biotechnology, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [___________] all of or [____________] shares of the foregoing Series B Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Phytomedical Technologies Inc, Phytomedical Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. The Warrant Shares shall be delivered to the following DWAC Account Number or by physical delivery of a certificate to: [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Eyegate Pharmaceuticals Inc, Eyegate Pharmaceuticals Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of Series B Preferred Stock of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [/ _______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Maxwell Resources, Inc., Fluoropharma Medical, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________________________________________________________________ Name of Authorized Signatory: ____________________________________________________________________________________________________________________ Title of Authorized Signatory: _____________________________________________________________________________________________________________________ Date: ________________________________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to ________________________________________________________________________________ whose address is ______________________________________________________________________________________________. ______________________________________________________________________________________________ Dated: ______________, _______ Holder’s Signature: ______________________________________________ Holder’s Address: ______________________________________________ ______________________________________________ Signature Guaranteed: _____________________________________________________________________________
Appears in 2 contracts
Samples: Atlantic Syndication Network Inc, Atlantic Syndication Network Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Jayhawk Energy, Inc., Jayhawk Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Reflect Scientific Inc, Blink Logic Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 2 contracts
Samples: Underwriting Agreement (iSpecimen Inc.), NRX Pharmaceuticals, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: ______________________________ _______________________________
Appears in 2 contracts
Samples: SQL Technologies Corp., SQL Technologies Corp.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ___________________________________________________________________________ Name of Authorized Signatory: _____________________________________________________________________________________________ Title of Authorized Signatory: ______________________________________________________________________________________________ Date: _________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Towerstream Corp), Underwriting Agreement (Towerstream Corp)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Biovie Inc.), Underwriting Agreement (Biovie Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ___________________________________________________ Name of Authorized Signatory: _____________________________________________________________________ Title of Authorized Signatory: ______________________________________________________________________ Date: _________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (CEA Industries Inc.), Underwriting Agreement (Immuron LTD)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [_________] all of or [_________] shares of the foregoing Series B Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: International Energy, Inc., Entheos Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: _________________________________________________________________________ Warrant Holder’s EIN: ___________________________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: __________________________________________________ Name of Authorized Signatory: ____________________________________________________________________ Title of Authorized Signatory: _____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature:_________________________________ Holder’s EIN: _____________________________________ Holder’s Address: :__________________________________ __________________________________ Signature Guaranteed: ___________________________________________________
Appears in 1 contract
Samples: Fuel Performance Solutions, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: ____________:_____________________________ Name of Authorized Signatory: ____________:_______________________________________________ Title of Authorized Signatory: ____________:________________________________________________ Date: _____________:___________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Genius Brands International, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _:________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ _whose address is ________________________________________________________________ . _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Us Geothermal Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________________ Name of Authorized Signatory: ________________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ____________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Mobilicom LTD
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ 82 ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Underwriting Agreement (Innovation Beverage Group LTD)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply the required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: CorMedix Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Underwriting Agreement (Immuron LTD)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________ Name of Authorized Signatory: _________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________ Date: _____________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Patient Safety Technologies, Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ DatedDate: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: CrowdGather, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [[ _______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Lithium Exploration Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. ________________________________________________________________________ Signature of Holder ________________________________________________________________________ Name of Investing Entity: Entity ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: Entity _________________________________________________ Name of Authorized Signatory: Signatory ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ Date ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) TO: NDB Energy, Inc. 10000 Xxxxxxxxxx, Xxxxx 0000 Houston, Texas 77042 FOR VALUE RECEIVED, [___________] all of or [____________] shares of the foregoing Series A Warrant of NDB Energy, Inc. and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, ____20___ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: NDB Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Xxxxxx's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Spindle, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ . Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: PDG Environmental Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ____________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ____________________________________________________________________ Name of Authorized Signatory: ____________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: _________________ Date:________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: CareView Communications Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [___________] all of or [____________] shares of the foregoing Series C Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Hepalife Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: :_______________________________________________________________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: :________________________________________________________________________________________________________________________________________ Name of Authorized Signatory: :__________________________________________________________________________________________________________________________________________________________ Title of Authorized Signatory: :___________________________________________________________________________________________________________________________________________________________ Date: :______________________________________________________________________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: ___________________________________________________________ Holder’s Address: ___________________________________________________________ ___________________________________________________________ _____________________________ _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Boston Therapeutics, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ Exhibit 4.1 ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is to: ____________________________________________________ whose address is: ____________. ________________________________________ ____________________________________________________ Dated: ___________________, ______________ Holder’s Signature: ____________________________________________________ Holder’s Address: ____________________________________________________ ____________________________________________________ Signature Guaranteed: ____________________________________________________
Appears in 1 contract
Samples: Innovate Biopharmaceuticals, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ EXHIBIT 4 ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantpurchase shares.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to ___Name: ____________________________________________ whose address is (Please Print) Address: ____________________________________________ (Please Print) Phone Number: ____________________. ________________________ Email Address: _____________________________________________ Dated: _______________ __, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________EXHIBIT 5 AUTHORIZED REPRESENTATIVES Name Title Signature Mxxxx Xxxxxx President/ Chief Executive Officer
Appears in 1 contract
Samples: Warrant Agent Agreement (bioAffinity Technologies, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned represents and warrants that it is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) To: STRATEGIC AMERICAN OIL CORPORATION Suite 2015, 600 Xxxxxxx Xxxxxx Xxxxxx Xxxxxxx, Xxxxx 00000 with a copy TO: LANG MXXXXXXX LLP 1000- 0000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx, Xxxxxx X0X 0X0 FOR VALUE RECEIVED, [____] all of or [_______] shares issuable upon exercise of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________.
Appears in 1 contract
Samples: Strategic American Oil Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityRegistered Holder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityRegistered Holder: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantRight, execute this form and supply required information. Do not use this form to exercise the warrantRight.) VIVEVE MEDICAL, INC. FOR VALUE RECEIVED, the undersigned, hereby assigns in accordance with the terms and conditions of the Right to Shares Letter Agreement, dated as of September 23, 2014 (the “Letter Agreement”) [____] all of or [_______] shares of the foregoing Warrant Right (as defined in the Letter Agreement) and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ HolderPurchaser’s Signature: _____________________________ HolderPurchaser’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Right to Shares Letter Agreement (Viveve Medical, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: BioMETRX
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: _______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ ______________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Aspen Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________:_______________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________:__________________________ Name of Authorized Signatory: ________:___________________________________________________ Title of Authorized Signatory: __________:__________________________________________________ Date: _____:___________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: :_____________________________ Holder’s 's Address: :_______________________________ Signature Guaranteed:_____________________________________________
Appears in 1 contract
Samples: On2 Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exerciseexercise and no registration statement covering the issuance of the Warrant Shares is effective, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: G Medical Innovations Holdings Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing EntitySIGNATURE OF AUTHORIZED SIGNATORY OF INVESTING ENTITY: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is ________________________________________________________________. ________________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Able Energy Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [_______] all of or [___________] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is ________________________________________________________________. ________________________________________________________________ Dated: ______________, _______ Holder’s Signature: ___________________________________ Holder’s Address: ___________________________________ ___________________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Cybra Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: _______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s AddressSignature: _____________________________ _________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Zealous Trading Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Aethlon Medical Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________________________________________ Name of Authorized Signatory: ____________________________________________________________________________________________ Title of Authorized Signatory: _____________________________________________________________________________________________ Date: __________________________________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ ________________________________
Appears in 1 contract
Samples: Generation Income Properties, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Hillstream BioPharma Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Derycz Scientific Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: _______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantWarrant referenced herein, execute this form and supply required information. Do not use this form to exercise the warrantWarrant.) FOR VALUE RECEIVED, [____] hereby sells, assigns and transfers [all of of] or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is is: _______________________________________________________________. _______________________________________________________________ Dated: ______________, ,_______ Holder’s Signature: ______________________________ Holder’s Address: _______________________________ _____________________________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Common Stock Purchase Warrant (Bionik Laboratories Corp.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [_________] all of or [_________] shares of the foregoing Series A Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Entheos Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________ Date: _____________________________________________________________________________________________________________________ EXHIBIT C ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the [principal amount of the Senior Secured Convertible Notes] [Common Stock] [Subsequent Financing Securities] [Qualified Financing Securities] issuable upon exercise of the foregoing Warrant and all rights evidenced thereby are hereby assigned to ____________________________________________________________________ whose address is _______________________________________________________________. __________________ .. _________________________________________________________________________________ Dated: _______________ , _______ Holder’s Signature: ________________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Applied Dna Sciences Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________ Name of Authorized Signatory: __________________________________________________________________ Title of Authorized Signatory: ___________________________________________________________________ Date: ______________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _______________________________
Appears in 1 contract
Samples: Lilis Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant to purchase shares.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is Name: _________________________________________________ (Please Print) Address: _______________. __________________________________ Phone Number: Email Address: (Please Print) _________________________________________________ _________________________________________________ Dated: _______________ __, _______ Holder’s Signature: _______________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Dermata Therapeutics, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Staffing 360 Solutions, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. information Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned certifies that it is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________________________________________________ Name of Authorized Signatory: __________________________________________________________________________________________________________ Title of Authorized Signatory: ___________________________________________________________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, _________ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _________________________whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
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Samples: Zurvita Holdings, Inc.
