FORM OF ELECTION TO PURCHASE Sample Clauses

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by this Rights Certificate) To: Xxxx Industries, Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Certificate to purchase the shares of Common Stock or other securities, cash or other property issuable upon the exercise of the Rights and requests that certificates for the shares or other securities be issued in the name of, and such cash or other property be paid to: Please insert social security or other identifying number (Please print name and address) If the number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the remaining balance of the Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number (Please print name and address) Dated: ,19__ Signature (Signature must conform in all respects to name of holder as specified on the face of this Rights Certificate)
FORM OF ELECTION TO PURCHASE. (To be executed by the Holder to exercise the right to purchase shares of Common Stock under the foregoing Warrant) To CirTran Corproation: In accordance with the Warrant enclosed with this Form of Election to Purchase, the undersigned hereby irrevocably elects to purchase [___________] shares of Common Stock ("Common Stock"), $.001 par value per share, of CirTran Corporation, and encloses herewith $________ in cash or certified or official bank check or checks, which sum represents the aggregate Exercise Price (as defined in the Warrant) for the number of shares of Common Stock to which this Form of Election to Purchase relates, together with any applicable taxes payable by the undersigned pursuant to the Warrant. The undersigned requests that certificates for the shares of Common Stock issuable upon this exercise be issued in the name of PLEASE INSERT SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER ________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ If the number of shares of Common Stock issuable upon this exercise shall not be all of the shares of Common Stock which the undersigned is entitled to purchase in accordance with the enclosed Warrant, the undersigned requests that a New Warrant (as defined in the Warrant) evidencing the right to purchase the shares of Common Stock not issuable pursuant to the exercise evidenced hereby be issued in the name of and delivered to: ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ Dated: ___________________ ,______ Name of Holder: (Print)_________________________ (By:)___________________________ (Name:)_________________________ (Title:)________________________ (Signature must conform in all respects to name of holder as specified on the face of the Warrant) [To be completed and signed only upon transfer of Warrant] FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers unto ________________________________ the right represented by the within Warrant to purchase ____________ shares of Common Stock of CirTran Corporation, to whic...
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: INTERPHASE CORPORATION The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Rights Certificate to purchase the shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ---------------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- 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: Please insert social security or other identifying number ---------------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated: , --------------------- ----- ----------------------------------------- Signature Signature Guaranteed: CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: SORRENTO THERAPEUTICS, INC.: The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number (Please print name and address) 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: Please insert social security or other identifying number (Please print name and address) Dated: , Signature Signature Guaranteed: Signatures must be guaranteed by a participant in the Medallion Signature Guarantee Program at a guarantee level acceptable to the Company’s Rights Agent.
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: iPayment, Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series A Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to:_________________ Please insert social security or other identifying number:____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ Dated: _______________, 200_ ________________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To:______________________ The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person or such other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or such other securities of the Company or of any other person or such other property as may be issuable upon the exercise of the Rights) be issued in the name of and delivered to: (Please print name and address) Please insert social security or other identifying 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: (Please print name and address) Please insert social security or other identifying number: Dated _____________, ______. Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) TO: DOVER DOWNS GAMING & ENTERTAINMENT, INC. The undersigned hereby irrevocably elects to exercise ______________________________________ Rights represented by this Right Certificate to purchase the shares of Common Stock issuable upon the exercise of such Rights and requests that certificates for such share(s) be issued in the name: ______________________________________________________ (Please print name and address) Please insert social security or other tax identifying number If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: ______________________________________________________ (Please print name and address) Please insert social security or other tax identifying number _________________________________________ Dated: ______________ ____, 20_______ ______________________ Signature (Signature must conform in all respects to name/s of holder/s as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an "eligible guarantor institution" as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended. The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. The undersigned hereby irrevocably elects to exercise the right, represented by this Warrant Certificate, to purchase ______ shares of Common Stock and/or ______Redeemable Warrants and herewith tenders in payment for such securities a certified or cashier's check or money order payable to the order of Room Plus, Inc. in the amount of $______, all in accordance with the terms hereof. The undersigned requests that certificates for such securities be registered in the name of ___________________________ whose address is _____________________ and that such certificates be delivered to _____________________________________ whose address is______________________________________________________________. Dated: Signature_______________________ (Signature must conform in all respects to the name of holder as specified on the face of the Warrant Certificate.) (Insert Social Security or Other Identifying Number of Holders)
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To:___________________ The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Rights Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Company or of any other person that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying 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: Please insert social security or other identifying number ------------------------------------------------------------------------ ------------------------------------------------------------------------ Dated: _____________ ___, ____ ------------------------- Signature Signature Guaranteed: