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 78 contracts
Samples: Underwriting Agreement (Red Cat Holdings, Inc.), Underwriting Agreement (QSAM Biosciences, Inc.), Underwriting Agreement (Lantern Pharma 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: Securities Purchase Agreement (Ortec International Inc), Common Stock Purchase Warrant (Cord Blood America, Inc.), Shares Purchase Warrant Agreement (Moventis Capital, 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 35 contracts
Samples: Underwriting Agreement (Immuron LTD), Underwriting Agreement (Transcode Therapeutics, Inc.), Underwriting Agreement (Lirum Therapeutics, 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.), Jerrick Media 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 [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 (Strong Global Entertainment, Inc), Underwriting Agreement (Biovie 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 [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 (Hillstream BioPharma Inc.), Underwriting Agreement (CytoMed Therapeutics 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 11 contracts
Samples: Underwriting Agreement (Harbor Custom Development, Inc.), Underwriting Agreement (BriaCell Therapeutics Corp.), S Warrant Agreement (Guardion Health Sciences, 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 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 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), Id-Confirm, 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 11 contracts
Samples: Underwriting 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 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: Common Stock Purchase Warrant (Hpev, Inc.), Hpev, Inc., DigiPath,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 7 contracts
Samples: Preferred Stock Purchase Warrant (OverNear, Inc.), Common Stock Purchase Warrant (OverNear, Inc.), As Seen on TV, 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 (Alta Global Group LTD), Underwriting Agreement (Azitra, Inc.), 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 (EzFill Holdings Inc), Underwriting Agreement (EzFill Holdings Inc), Underwriting Agreement (EzFill Holdings 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 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 (Azitra Inc), Underwriting Agreement (Rise Oil & Gas, 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.), Common Stock Purchase Warrant (Amesite Inc.), Theralink 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 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 4 contracts
Samples: Wifimed Holdings Company, Inc., Wifimed Holdings Company, Inc., MeeMee Media 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), Toughbuilt Industries, Inc, Akers Biosciences 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 (Fat Brands, Inc), 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 4 contracts
Samples: Underwriting Agreement (Catasys, Inc.), Underwriting Agreement (Virios Therapeutics, LLC), 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.), Vallon Pharmaceuticals, Inc., Odd Burger 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: Lilis Energy, Inc., ONCOSEC MEDICAL 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: Red Metal Resources, Ltd., Digital Angel Corp, Digital Angel 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 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: ________________________________________________________________________________ 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: Photovoltaic Solar Cells, Inc., Peoples Liberation Inc, MetaStat, 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 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 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 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 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 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: _______:_________________________________________________________________________ Original Date of Issuance: ___________ Reissuance Date: December 19, 2007 Warrant No.: _________________ Expires: ___________________ 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: Chembio Diagnostics, Inc., Siebert Lawrence A.
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 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 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 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 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: _______________________ 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 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 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 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 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 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. 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 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 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 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 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: H & H Imports, Inc., H & H Imports, 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: ________________________________________________________________________ Original Date of Issuance: October 5, 2006 Reissuance Date: December 19, 2007 Warrant No.: ___________________ Expires: October 5, 2011 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: Siebert Lawrence A., Chembio Diagnostics, 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 2 contracts
Samples: Underwriting Agreement (Biovie Inc.), Underwriting Agreement (Biovie 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 undersigned represents that the Warrant is being exercised via cash exercise, representations set forth in Section 2.2(d) – (j) of the undersigned is an “accredited investor” Purchase Agreement are true and correct as defined in Regulation D promulgated under of the Securities Act date of 1933, as amended this Notice of Exercise. [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: XCel 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: :_____________________________ _____________________________ Signature Guaranteed:____________________________________________
Appears in 1 contract
Samples: Wave Uranium Holding
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 to_______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Transcode 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 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: Datajungle Software 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: Retrophin, 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: Akeena Solar, 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
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 1 contract
Samples: Trist 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 1 contract
Samples: Marizyme, 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 Signature: Holder’s Address: _____________________________ _____________________________:
Appears in 1 contract
Samples: Underwriting Agreement (Harbor Custom Development, 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 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: Draganfly 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: ________________________________________________________________________________ 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 1 contract
Samples: 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 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.) SYSOREX, INC. FOR VALUE RECEIVED, the undersigned, Inpixon hereby assigns in accordance with the terms and conditions of the Right to Shares Letter Agreement, dated as of April 14, 2021 (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: ______________, _______ Holder’s Signature: ______________________________ Holder’s Address: _______________________________ _______________________________ Signature Guaranteed: ____________________________________________________
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 [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 (Hepion 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 SignatoryNAME OF INVESTING ENTITY: ___________________________________________________________ Title of Authorized SignatorySIGNATURE OF AUTHORIZED SIGNATORY OF INVESTING ENTITY: _________________________________________ NAME OF AUTHORIZED SIGNATORY: ___________________________________________________________ TITLE OF AUTHORIZED SIGNATORY: ___________________________________________________________ DateDATE: ________________________________________________________________________________ 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: Placement Agency 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 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 1 contract
Samples: Can-Fite BioPharma Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is either (i) an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended, or (ii) not a “U.S. Person” as such term is defined in Regulation S 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 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 _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Name: exercise (Please Print) Address: (Please Print) Phone Number: Email Address: Dated: _______________ __, _______ Holder’s Signature: _______:______________________ Holder’s Address: :_____________________________ _____________________________
Appears in 1 contract
Samples: SONDORS 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] 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
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: _____________________________ _____________________________
Appears in 1 contract
Samples: GeoVax Labs, 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 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 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: ____________________________________________________________________________________________ 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 1 contract
Samples: Origin Life 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 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Oxis 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: Four Rivers Bioenergy Inc.
Accredited Investor. If the Warrant is being exercised via cash exerciseThe undersigned, and, if applicable, the undersigned person or entity identified in subsection 3 above, 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: Rapid Link 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: Mdi, 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 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 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 1 contract
Samples: 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 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: World Waste 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: _______________________________________________________________ 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: Sionix 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: ________________________________________________________________________________ 4837-5958-0157.1 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 _______________________________________________________________. _______________________________________________________________ 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 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 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: ________________________________________________________________________________ 77 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 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: _____________________________ _____________________________whose address is
Appears in 1 contract
Samples: S Warrant Agreement (LMP Automotive Holdings, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exerciseexercise and the registration statement registering the issue of the shares under the Warrant is no longer effective, 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 _______________________________________________________________ASSIGNMENT FORM (To assign the foregoing Warrant, execute this form and supply required information. _______________________________________________________________ Do not use this form to purchase shares.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to Name: (Please Print) Address: (Please Print) Phone Number: Email Address: Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ __, ____________________________ Holder’s Signature:
Appears in 1 contract
Samples: Coya Therapeutics, 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.)
