Common use of FORM OF ELECTION TO EXERCISE Clause in Contracts

FORM OF ELECTION TO EXERCISE. TO: The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Address Social Insurance, Social Security or Other Taxpayer Identification Number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Address Social Insurance, Social Security or Other Taxpayer Identification Number Date: _____________________________________________________ Signature Signature Guarantee: (Signature must correspond to the name as written upon the face of the Rights Certificate, in every particular, without alteration or enlargement, or any change whatsoever). Signature must be guaranteed by a Canadian chartered bank, or an eligible guarantor institution with membership in an approved Medallion signature guarantee program. (To be completed by the exercisor if true) The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in concert therewith. Capitalized terms shall have the meaning ascribed thereto in the Rights Agreement. Signature (please print name of Signatory)

Appears in 1 contract

Samples: Shareholder Rights Plan Agreement (Hemisphere Energy Corp)

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FORM OF ELECTION TO EXERCISE. TO: The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Address Social Insurance, Social Security or Other Taxpayer Identification Number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Address Social Insurance, Social Security or Other Taxpayer Identification Number Date: _____________________________________________________ Signature Signature GuaranteeGuaranteed: (Signature must correspond to the name as written upon the face of the this Rights Certificate, Certificate in every particular, without alteration or enlargement, enlargement or any change whatsoever). ) Note: Signature must be guaranteed by a major Canadian trust company, a Schedule I Canadian chartered bank, or an eligible guarantor institution with membership in an approved a member of a recognized Medallion signature guarantee Guarantee program. (To be completed by the exercisor if true) The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in concert therewith. Capitalized terms shall have the meaning ascribed thereto in the Rights Agreement. Signature (please print name of Signatory)

Appears in 1 contract

Samples: Shareholder Protection Rights Plan Agreement (Bakbone Software Inc)

FORM OF ELECTION TO EXERCISE. TO: The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the this Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares Shares be issued in the name ofof and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number Date: _____________________________________________________ Signature Signature Guarantee: (Signature must correspond to the name as written upon the face of the this Rights Certificate, Certificate in every particular, without alteration or enlargement, enlargement or any change whatsoever). ) Signature Guaranteed Signature must be signature guaranteed by a Schedule 1 Canadian chartered bank, a Canadian major trust company or an eligible guarantor institution with membership in an approved a member firm of a recognized Medallion signature guarantee programSignature Guarantee Program. (To be completed by the exercisor holder if true) The undersigned hereby certifies and represents, for the benefit of the Corporation and all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, not and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or by an Affiliate or Associate thereof of an Acquiring Person or by any other Person acting jointly or in concert therewith. Capitalized with any of the foregoing (as such terms shall have the meaning ascribed thereto are defined in the Rights Agreement). Signature (please Please print name below signature) NOTICE In the event that the certification set forth above in the Form of Signatory)Election to Exercise is not completed, the Corporation shall deem the Beneficial Owner of the Rights represented by this Rights Certificate to be an Acquiring Person (as defined in the Rights Agreement) and, accordingly, such Rights shall be null and void.

Appears in 1 contract

Samples: Shareholder Rights Plan Agreement (Aeterna Zentaris Inc.)

FORM OF ELECTION TO EXERCISE. TO: The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the this Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares Shares be issued in the name ofof and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number Date: _____________________________________________________ Signature Signature Guarantee: (Signature must correspond to the name as written upon the face of the this Rights Certificate, Certificate in Signature Guaranteed every particular, without alteration or enlargement, enlargement or any change whatsoever). ) Signature must be guaranteed Signature Guaranteed by a Schedule 1 Canadian chartered bank, a major Canadian trust company or an eligible guarantor institution with membership in an approved a member of a recognized Medallion signature guarantee Guarantee program. (To be completed by the exercisor holder if true) The undersigned hereby certifies and represents, for the benefit of the Corporation and all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, not and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or by an Affiliate or Associate thereof of an Acquiring Person or by any other Person acting jointly or in concert therewith. Capitalized with any of the foregoing (as such terms shall have the meaning ascribed thereto are defined in the Rights Agreement). Signature (please Please print name of Signatorybelow signature)

Appears in 1 contract

Samples: Shareholder Rights Plan Agreement (Gildan Activewear Inc.)

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FORM OF ELECTION TO EXERCISE. TO: GTR GROUP INC. The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares Shares be issued in the name ofto: Address (Address) (City and State or Province) Social Insurance, Social Security or Other Taxpayer Identification Number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Address (Address) (City and State or Province) Social Insurance, Social Security or Other Taxpayer Identification Number Date: _____________________________________________________ Date Signature Guaranteed Signature Guarantee: (Signature must correspond to the name as written upon the face of the this Rights Certificate, Certificate in every particular, . without alteration or enlargement, enlargement or any change whatsoever). ) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company or an eligible guarantor institution with membership in an approved a member of a recognized stock exchange or a member of the Transfer Association Medallion signature guarantee program(Stamp) Program. ([To be completed by the exercisor if true) ] The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in concert therewith. Capitalized terms shall have with any of the meaning ascribed thereto foregoing (as defined in the Rights Agreement). Signature (please print name of Signatory)Signature

Appears in 1 contract

Samples: Shareholder Rights Plan Agreement (Mad Catz Interactive Inc)

FORM OF ELECTION TO EXERCISE. TO: The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the this Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares Shares be issued in the name ofof and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Name Address City and Province Social Insurance, Social Security Insurance No. or Other Taxpayer Identification Number other taxpayer identification number Date: _____________________________________________________ Signature Signature Guarantee: (Signature must correspond to the name as written upon the face of the this Rights Certificate, Certificate in every particular, without alteration or enlargement, enlargement or any change whatsoever). ) Signature Guaranteed Signature must be guaranteed Signature Guaranteed by a Schedule 1 Canadian chartered bank, a major Canadian trust company or an eligible guarantor institution with membership in an approved a member of a recognized Medallion signature guarantee Guarantee program. (To be completed by the exercisor holder if true) The undersigned hereby certifies and represents, for the benefit of the Corporation and all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, not and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or by an Affiliate or Associate thereof of an Acquiring Person or by any other Person acting jointly or in concert therewith. Capitalized with any of the foregoing (as such terms shall have the meaning ascribed thereto are defined in the Rights Agreement). Signature (please Please print name of Signatorybelow signature)

Appears in 1 contract

Samples: Shareholder Rights Plan Agreement (Gildan Activewear Inc.)

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