FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) To: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 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 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 2 contracts
Samples: Rights Agreement (Orapharma Inc), Rights Agreement (Orapharma Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTo CBL & Associates Properties, Inc.: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 print name and address) address ________________________________________________________________________________ (Please insert social security or other identifying number) : __________________ If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: ________________________________________________________________________________ (Please print name and address) address ________________________________________________________________________________ (Please insert social security or other identifying number) : Dated:______: _________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.[Signature] Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (CBL & Associates Properties Inc), Rights Agreement (CBL & Associates Properties Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) To: ORAPHARMA, INC. Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such Rights (or such other securities or property of the Company or of any other person 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 toof: ___________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ Dated: Signature Signature Medallion Guaranteed: _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of a registered United States national securities exchange1934, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United Statesas amended.
Appears in 2 contracts
Samples: Rights Agreement (Pericom Semiconductor Corp), Rights Agreement (Pericom Semiconductor Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: ORAPHARMA, INCONEIDA LTD. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person Person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., Please insert social security or a commercial bank or trust company having an office or correspondent in the United States.other identifying number:
Appears in 2 contracts
Samples: Rights Agreement (Oneida LTD), Rights Agreement (Oneida LTD)
FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise the Right Rights evidenced by this Rights Certificate.) To: ORAPHARMA, INC. MIM CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Right Rights Certificate to purchase the shares of Series E Preferred Stock Units issuable upon the exercise of such the Rights (or such other securities securities, cash or property 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 Units (or such other securities which may be issuable upon the exercise of the Rights) be issued in the name of and delivered to: Please insert social security or other identifying number: ________________________________ __________________________________________________ (Please print name and addressname) __________________________________________________ __________________________________________________ (Please insert social security or other identifying numberprint address) If such number of Rights shall not be all of the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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 addressname) __________________________________________________ __________________________________________________ (Please insert social security or other identifying numberprint address) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ______________________________________, Signature: _______________________________________ Signatures must be guaranteed by a member firm (Sign exactly as your name appears on the other side of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.this Rights Certificate) Signature Guarantee: _____________________________
Appears in 2 contracts
Samples: Rights Agreement (Mim Corp), Rights Agreement (Mim Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. INSTINET GROUP INCORPORATED The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) _______________________________________________________________________________ (Please insert social security or other 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 identifying number) Dated:: _______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Instinet Group Inc), Rights Agreement (Instinet Group LLC)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. Xxxx-Xxxxx Company: The undersigned hereby irrevocably elects to exercise ______________________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such Rights (or such other securities of the Company or of any other person Person which may be issuable upon the exercise of the Rights) ), and requests that certificates for such shares (or other securities) be issued in the name of and delivered toof: _____________________________________________________________________________ (Please print name and address) Please insert social security or other identifying number: _______________________________________________ (Please insert social security or other 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 identifying number: ________________________________________________ (Please insert social security or other identifying number) DatedThe undersigned hereby certifies, by marking the appropriate boxes, that:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 2 contracts
Samples: Stockholder Rights Agreement (Nash Finch Co), Stockholder Rights Agreement (Nash Finch Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAPHARMATHENE, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ):____________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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:___________________________________ (Please print name and address) ____________Signature: ________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Section 382 Rights Agreement (Pharmathene, Inc), Section 382 Rights Agreement (Pharmathene, Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) ToTo Owens Corning: ORAPHARMA, INC. The undersigned hereby irrevocably herexx xxrevocably elects to exercise exer cise _______________ Rights represented by this Right Certificate Cer tificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 certifi cates for such shares be issued in the name of and delivered toof: Xxease insert social security or other identifying number __________________________________________________________ (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 evi denced 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 insert social security or other identifying number __________________________________________________________ (Please print name and address) __________________________________________________________ (Please insert social security or other identifying number) Dated:__________________, ____ [Form of Election to Purchase -- continued] __ _________________________ Signature (Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm conform in all respects to name of a registered United States national securities exchange, a member holder as specified on the face of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United Statesthis Right Certificate.)
Appears in 2 contracts
Samples: Rights Agreement (Owens Corning), Rights Agreement (Owens Corning)
FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. Swift Energy Company The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E A Junior Participating Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series A Junior Participating Preferred Stock (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 Right Rights Certificate, a new Right Rights 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 identifying number) :________________________ Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Swift Energy Co), Rights Agreement (Swift Energy Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) ToTo The Sherxxx-Xxxxxxxx Xxxpany: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 toof: Please insert social security or other identifying number: _____________________________________________ _______________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated:_________________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.19__ ----------------------------------- Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Sherwin Williams Co), Rights Agreement (Sherwin Williams Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. State Street Bank and Trust Company The undersigned hereby irrevocably elects to exercise ___________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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) ___________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _________________ Dated: ______________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Reverse Side of Rights Certificate Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Lifeline Systems Inc), Rights Agreement (Lifeline Systems Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAWINSTAR COMMUNICATIONS, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:: ________________ Dated: _________ __, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Winstar Communications Inc), Rights Agreement (Winstar Communications Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, BETZDEARBORN INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock Common Shares issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which 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 -------------------------------------------------------------------------------- (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_______________: , _____ _______________________ ----------- ------ ------------------------------------ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 2 contracts
Samples: Rights Agreement (Betzdearborn Inc), Rights Agreement (Betzdearborn Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: ORAPHARMA, VERADIGM INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number: ______________________ ________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: _______________________ 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature GuaranteedDated: _________________, _______ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Veradigm Inc.), Rights Agreement (Veradigm Inc.)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAINTERNET CAPITAL GROUP, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 print name and address) __________________________________________________ (Please insert print social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights 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 print social security or other identifying number) Dated:_______________, _____ ______________________________ Signature Signature Guaranteed: :__________________________ Signatures must be guaranteed The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Internet Capital Group Inc), Rights Agreement (Internet Capital Group Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights represented by this Rights Certificate.) To: ORAPHARMAValassis Communications, INC. Inc. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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: ____________________________________________ Rights represented by this Rights Certificate to purchase the shares of preferred 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 the cash or other property be paid to: Please insert social security or other identifying number --------------------------------------------------------- (Please print name and address) _____________________________________________ (Please insert social security or other identifying number) --------------------------------------------------------- If such the number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the remaining balance remaining of such 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: ____________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ ___________________,____ Signature --------------------------- (Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm conform in all respects to name of a registered United States national securities exchange, a member holder as specified on the face of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.this Rights Certificate)
Appears in 2 contracts
Samples: Rights Agreement (Valassis Communications Inc), Rights Agreement (Valassis Communications Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. Masco Corporation The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ___________________________________________________________ (Please insert social security or other identifying number) Dated:: ________________, 19__ _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Masco Corp /De/), Rights Agreement (Masco Corp /De/)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMAOMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such the Rights (or such other securities of the Company Corporation 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 toof: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented 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 insert social security or other 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) Date:______________ , 19__ ______________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Omega Worldwide Inc), Omega Worldwide Inc
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise To __________ _____: The undersigned hereby irrevocably elects to exercise Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) __________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________________________ Dated: _________, _20____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Forgent Networks Inc), Rights Agreement (Forgent Networks Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. Adobe Systems Incorporated The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 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 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 of such Rights shall be registered in the name of and delivered to: (Please print name and address) Dated:____________________________________________ Please insert social security or other identifying number: _____________ Dated: _________________ ____, _______ __________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 2 contracts
Samples: Rights Agreement (Adobe Systems Inc), Rights Agreement (Adobe Systems Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights evidenced by the Right Rights Certificate.) To: ORAPHARMABURLINGTON INDUSTRIES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented evidenced by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or other property that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature GuaranteedPlease insert social security or other identifying number: ______________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated: , a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.199 /200 ---------------------- Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Burlington Industries Inc /De/), Rights Agreement (Burlington Industries Inc /De/)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. CD Radio Inc. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock B Shares (or fractions thereof) issuable upon the exercise of such Rights (or such other securities of the Company or of any other person which entity 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 toof: Please insert social security or other identifying number: ___________________________________ ___________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _________ _______________________ Signature Signature Guaranteed: _____________________________________________ Signatures must be guaranteed Dated: __________________, 19__ _________________________ Signature Signature Guaranteed: CERTIFICATE The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 2 contracts
Samples: Rights Agreement (Cd Radio Inc), Rights Agreement (Cd Radio Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, ANCHOR BANCORP WISCONSIN INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock A Shares (or fractions thereof) issuable upon the exercise of such Rights (or such other securities of the Company or of any other person which entity 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 toof: Please insert social security or other identifying number: ______________________________ ___________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: _____________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated: __________________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.[19][20]__ ________________________ Signature Signature Guaranteed:
Appears in 2 contracts
Samples: Rights Agreement (Anchor Bancorp Wisconsin Inc), Rights Agreement (Anchor Bancorp Wisconsin Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) ToTo Chrysler Corporation: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such Rights (or such other securities of the Company or of any other person 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 toof: Please insert social security or other identifying number ________________________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated:__________________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.____
Appears in 1 contract
Samples: Rights Agreement (Chrysler Corp /De)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMADAKOTA TELECOMMUNICATIONS GROUP, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ___________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _________________ Dated: ______________, 19__ ___________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Dakota Telecommunications Group Delaware Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. UNIPHASE CORPORATION The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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: ). Dated _________________________________________, 199___ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ --------------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMANational Vision Associates, INC. Ltd. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares securities 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) _____________________________________________ (Please insert social security or other 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 toDated: ____________________, _______ ______________________________ (Please print name and address) ________________________________Signature Signature Guaranteed: Exhibit C ____________ (Please insert social security or other identifying number) Dated:_______________NATIONAL VISION ASSOCIATES, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm LTD. SHAREHOLDER RIGHTS PLAN Summary of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Terms
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAXXXXXXX ASSOCIATES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: ____________________________________________ 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 he 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: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. REALOGY CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ______________________________________________________________________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ____________________________________________________________________________________ _______________________ Signature Signature Guaranteed: ________________________________________________________________________________________________________________________ Signatures must be guaranteed Dated: , Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Realogy Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAInterface, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates (or registrations in uncertificated book-entry form on the books of the Company) for such shares securities 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) _____________________________________________ (Please insert social security or other 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 toDated: ____________________, _______ ______________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Exhibit C
Appears in 1 contract
Samples: Rights Agreement (Interface Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMAEagle River Interactive, INC. Inc. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such 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 toof: Please insert social security or other identifying number: ___________________ ___________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated:__________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.19__ _________________ Signature Signature Guaranteed:
Appears in 1 contract
Samples: Rights Agreement (Mastering Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAFURNITURE BRANDS INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E B Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series B Preferred Stock (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 Right Rights Certificate, a new Right Rights 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 identifying number) :________________________ Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
Samples: Rights Agreement (Furniture Brands International Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. MERIDIAN POINT REALTY TRUST VIII COMPANY The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person 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) ___________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:________________________________ Dated: _____________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Meridian Point Realty Trust Viii Co/Mo)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. Xxxxxx Trust and Savings Bank The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Preference Shares issuable upon the exercise of such 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: 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) _____________________________________________ (Please insert social security or other 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--------------------------------------------------------------------- --------------------------------------------------------------------- Dated: _________________________________________, 19___ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ ----------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Nicor Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMACHECKPOINT SYSTEMS, INC. The undersigned hereby irrevocably elects to exercise _____exercise_____ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Common Shares issuable upon the exercise of such 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 toof: Please insert social security or other identifying number ______________________ ________________________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ Dated: ___________ ___, ___ _____________________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by an eligible financial institution or broker who is a member firm of participant in a registered United States national securities exchange, a member of Medallion Program approved by the National Association of Securities DealersTransfer Association, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAINTEGRATED TECHNOLOGY USA, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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 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) 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) _________________________ Dated: ____________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ______________________________ Signatures Signature must be guaranteed by a member firm of a registered United States national securities exchange, a member of an Eligible Guarantor Institution as defined by SEC Rule 17Ad-15 (17 C.F.R. 240.17-Ad-15). Certificate The undersigned hereby certifies by checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights evidenced by the Right Rights Certificate.) To: ORAPHARMABURLINGTON INDUSTRIES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented evidenced by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or other property that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) : Dated:: ______________ __, ____199_/200_ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INCAEROCENTURY CORP. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ ). Dated ---------------- -------------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Aerocentury Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAUNITED DOMINION REALTY TRUST, INC. .: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E C Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number ______________________________________________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange(Please print name and address) 1 Date: _______________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.____ -------------------------------- Signature Signature Guaranteed:
Appears in 1 contract
Samples: Rights Agreement (United Dominion Realty Trust Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. XXXXXX FINANCIAL CORPORATION: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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) _____________________________________________ (Please insert social security or other 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: ____________________________________________ If such number 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ ________________________________________________________________________________ Signature Signature GuaranteedDated: ________________________, 19 __. __________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed: 6
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: ORAPHARMA, WHG RESORTS & CASINOS INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company WHG Resorts & Casinos Inc. 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) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ________________________________________________________________________________ (Please insert social security or other identifying number) Dated:_______________________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAAlkermes, INC. Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall will not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall will be registered in the name of and delivered to: Please insert social security or other identifying number ____________________________ ________________________________________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ Dated: ________________ ______, ____ _____________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Alkermes Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMASYBRON DENTAL SPECIALTIES, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) _______________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____________________ _______________________ Signature Signature Guaranteed: _________________________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated: _______________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States._____ ---------------------------------- Signature
Appears in 1 contract
Samples: Rights Agreement (SDS Holding Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAKEY TECHNOLOGY, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) _______________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) _______________________________________________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) To: ORAPHARMATo ANDOVER BANCORP, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 toof: Please insert social security or other identifying taxpayer number: __________________ ________________________________________________________________________________ (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 Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: _____________________ ________________________________________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ ________________________________________________________________________________ Dated: _________, __ _________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAFrontier Airlines, INC. Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which 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 print name and address) _____________________________________________ (Please insert social security or other identifying number) number If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) _______________________________ _______________________________ (Please insert social security or other identifying numberprint name and address) Dated:______________ __, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: ORAPHARMA, INCONEIDA LTD. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person Person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature GuaranteedPlease insert social security or other identifying number: ______________________________ Signatures must be guaranteed Dated: _________________, __ ---------------------------------------- Signature Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Oneida LTD)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. InterAmericas Communications Corporation The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ _______________________ Signature Signature Guaranteed: __________________________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated:______________________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.19___ ___________________________________ Signature Signature Guaranteed:
Appears in 1 contract
Samples: Rights Agreement (Interamericas Communications Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise any or all of the Rights represented by this Right Certificate.) To: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise ____________________________ (__________) of the Rights represented by this Right Certificate to purchase the shares of Series E Preferred the Common Stock of the Company, or other securities or property issuable upon the exercise of such said number of Rights (or such other securities of pursuant to the Company or of any other person which may be issuable upon the exercise of the Rights) and Rights Agreement. The undersigned hereby requests that certificates a certificate for any such shares securities and any such property be issued in the name of and delivered to: ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ (Please insert Name, address and social security or other identifying numbernumber of issuee) If such The undersigned hereby further requests that if said number of Rights shall not be all the Rights evidenced represented by this Right Certificate, a new Right Certificate for the remaining balance remaining of such Rights shall be registered issued in the name of and delivered to: ____________________________________________ (Please print name and address) _____________________________________ (Name, address and social security or other identifying number of issuee) Dated:______________________ ________________________________________ (Please insert social security or other identifying numberSignature) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Vantive Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. _________________________ The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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 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: ________________________ (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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered toDated: ____________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Shenandoah Telecommunications Co/Va/)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMACOVENTRY HEALTH CARE, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock Common Stock, issuable upon the exercise of such 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 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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered 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 print name and address) ________________________________________________________________________________ (________________________________________________________________________________ Please insert social security or other identifying number) : _____________________ Dated:_______________, _____ ______, [____]. ____________________________________ Signature Signature Guaranteed: _______________________________________________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.52
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, OPTIKA INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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: ). Dated ___________________ _________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate ----------- The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent appropriate boxes in the United States.(1) and (2) that:
Appears in 1 contract
Samples: Rights Agreement (Optika Inc)
FORM OF ELECTION TO PURCHASE. ([To be executed if by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) ] To: ORAPHARMA, INC. The Rights Agent The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person 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 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, ______________________ Please insert social security or other identifying number: ___________________ Dated: _________________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Nexmed Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. WYNDHAM WORLDWIDE CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ______________________________________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ____________________________________________________ _______________________ Signature Signature Guaranteed: ________________________________________________________________________________________ Signatures must be guaranteed Dated: , Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. BALLY ENTERTAINMENT CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company Corporation 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 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 Right Rights Certificate, a new Right Rights 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 identifying number) :______________________________________________________ Dated:_______________, ___19__ ________________________ Signature Signature Guaranteed: _____________. Certificate ___________ Signatures must be guaranteed The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. L. X. Xxxxxx Company: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which 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 ______________________________ (Please print name and address) ______________________________ ______________________________ (Please insert social security or other identifying numberprint name and address) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ______________________________ ______________________________ (Please insert social security or other identifying numberprint name and address) Dated:_____________ ___, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed::
Appears in 1 contract
Samples: Rights Agreement (Foster L B Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. TREDEGAR CORPORATION: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number _______________________________________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) _______________________________________________________________________ (Please insert social security or other identifying number) Dated:Date: _______________, ____ __ __________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Tredegar Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. __________________________ The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, ____________________ Please insert social security or other identifying number_________________________________ Dated: _______________________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAOMNIQUIP INTERNATIONAL, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) :__________________________________________________ (Please insert social security or other identifying number) -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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:__________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated-------------------------------------------------------------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise the Right Rights Certificate.) ToTo Manatron, Inc.: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such Rights (or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of and delivered toof: Please insert social security or other tax identifying number: _______________________________________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance of remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other tax identifying number: _______________________________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____________ Dated: ___________________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: CERTIFICATE The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Manatron Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAINTELLIGENT ELECTRONICS, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: ____________________________________________ (Please print name and address) ______________________________ Please insert social security or other identifying number: __________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be he registered in the name of and delivered to: ____________________________________________ (Please print name and address) ______________________________ Please insert social security or other identifying number: _________________ (Please insert social security or other identifying number) Dated:: ______ __, 199_/200_ _______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. ACUSON CORPORATION The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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: ). Dated ___________________ _________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate ----------- The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent appropriate boxes in the United States.(1) and (2) that:
Appears in 1 contract
Samples: Rights Agreement (Acuson Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMASun Company, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred B Preference Stock issuable upon the exercise of such 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ___________________________________________________________ (Please insert social security or other identifying number) Dated:: ________________, 19__ _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Sun Co Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAORGANIC, INC. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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 identifying number) Dated:_______________, _____ _______________________ ). Dated ------------------------------- ------------------------------------ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Organic Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMASP VENTURES, INC. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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: _______________, ____ __________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate ----------- The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (McKesson Hboc Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. NUI CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 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: ___________________________________ (Please insert social security or other 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 toDated: __________________, 20__ ________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Nui Holding Co)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INCOCTEL CORP. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 print name and address) _____________________________________________ (Please insert print social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights 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 print social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: :________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.___
Appears in 1 contract
Samples: Rights Agreement (Octel Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. CTPartners Executive Search Inc. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E A Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series A Preferred Stock (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 Right Rights Certificate, a new Right Rights 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 identifying number) :________________________ Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
Samples: Rights Agreement (Ctpartners Executive Search Inc.)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. Stratus Properties Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number _____________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) _____________________________________________________________________ (Please insert social security or other identifying number) Dated:: ________________, 20__ _____ ________________________________ Signature Signature Guaranteed: ________________________ Signatures Signature must be guaranteed by a member firm of participant in a registered United States national securities exchange, Medallion Signature Guarantee Program at a member of guarantee level acceptable to the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United StatesCompany's Rights Agent.
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMAXxxxxx Industries, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 securities 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 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 insert social security or other 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) Dated: ________________, 20___ ___________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAWEBMETHODS, INC. .: The undersigned hereby irrevocably elects to exercise __________ ___________________Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 insert social security or other 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) ______________________Dated:______________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States._______
Appears in 1 contract
Samples: Rights Agreement (Webmethods Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMA, INC. XXXXXX LABORATORIES The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such 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 toof: ____________________________________________ (Please print name and address) _____________________________________________ (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 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 identifying number: ------------------------------------------------ ----------------------------------------------------------------------------- (Please print name and address) Dated:_______________: ----------------------, _____ _______________________ ---- -------------------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAMANATRON, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) _____________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) B-8 Dated:_: ______________, _____ _____________________20__ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed B-9 Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Manatron Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights Certificate.) To: ORAPHARMA, INC. [____________] The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such 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 Preferred Stock be issued in the name of and delivered toof: ____________________________________________ (Please print name and address) _____________________________________________ (Please insert social security or other identifying numberName) 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 addressAddress) ______________________________________________ (Please insert social Social security or other identifying number) Dated:A new Rights Certificate evidencing the remaining balance, if any, of such Rights not hereby exercised shall be mailed to and registered in the name of the undersigned unless such person requests that such Rights Certificate be registered in the name of and mailed to (complete only if a Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): _______________, _______________________________ (Name) ______________________________________________ (Address) ______________________________________________ (Social security or other identifying number) DATED: ______________, 20__ _____________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by an eligible guarantor institution with membership in a member firm of a registered United States national securities exchange, a member of recognized signature guarantee medallion program as approved by the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United StatesStock Transfer Association.
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: ORAPHARMAXxxxxxxxx-UTI Energy, INC. Inc. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number: ______________________ ______________________________________________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:__________________________________ Dated: ______________, _______ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: CERTIFICATE The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Stockholder Rights Agreement (Patterson Uti Energy Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. CALGON CARBON CORPORATION: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) _______________________________________________________________________________ (Please insert social security or other 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) Dated: _______________,__ ______________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMATHE CHEFS’ WAREHOUSE, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which or other property that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ ____________________________________________________ Signature Signature GuaranteedPlease insert social security or other identifying number: _____________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated: _____ __, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.202_ Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAJOHNXXXX XXXUSTRIES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E X Preferred Stock issuable upon the exercise of such 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) ______________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Dated: ----------------------- --------------------------------- Signature Signature Guaranteed:
Appears in 1 contract
Samples: Stockholder Protection Agreement (Johnston Industries Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. American Stock Transfer & Trust Company The undersigned hereby irrevocably elects to exercise ___________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which 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_____________________________________________________ ________________________________________________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ Dated: ________________ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) ToTo CTG Resources, Inc.: ORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares one one-hundredths of Series E a share of Preferred Stock or other securities issuable upon the exercise of such 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number: ______________________________________________ ___________________________________________________________________________ (Please print name and address) ____________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall is not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall will be registered in the name of and delivered to: Please insert social security or other identifying number:_______________________________________________ __________________________________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ________________ Dated: __________, ____ _________________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed CERTIFICATE ----------- The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (CTG Resources Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights represented by this Rights Certificate.) To: ORAPHARMABE AEROSPACE, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such 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 Units 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangePlease insert social security or other identifying number: Dated: ___________ __, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.____
Appears in 1 contract
Samples: Rights Agreement (Be Aerospace Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMASAGE, INC. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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: ). Dated ____________________________ __________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Sage Inc/Ca)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Certificate.) To: ORAPHARMATo BROOKTROUT TECHNOLOGY, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 toof: Please insert social security or other identifying taxpayer number: __________________ ________________________________________________________________________________ (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 Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: _____________________ ________________________________________________________________________________ (Please print name and address) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ ________________________________________________________________________________ Dated: ___________, ____ _________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.
Appears in 1 contract
Samples: Shareholder Rights Agreement (Brooktrout Technology Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMATrans World Airlines, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ___________________________________________________________ (Please insert social security or other identifying number) Dated:: ________________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAXxxxxxx, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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: ______________________________________________________________________________ (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) 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) ____________insert social security or other identifying number: ________________________________ Signature guaranteed (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., The New York Stock Exchange or a commercial bank or trust company having an office or correspondent in New York City): Certificate The undersigned hereby certifies by checking the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Wellman Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMASAGE, INC. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Rights Certificate to purchase the shares Units of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) 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 identifying number) Dated:_______________, _____ _______________________ ). Dated -------------------------------- -------------------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
Samples: Rights Agreement (Sage Inc/Ca)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights represented by this Rights Certificate.) To: ORAPHARMA, INC. CABLE DESIGN TECHNOLOGIES CORPORATION The undersigned hereby irrevocably elects to exercise ________________ ____________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock or other securities, cash or other property issuable upon the exercise of such 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 or other securities be issued in the name of of, and delivered such cash or other property be paid to: Please insert social security or other identifying number: ________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ A new Rights Certificate evidencing the remaining balance, if any, of such Rights not hereby exercised shall be mailed to and registered in the name of the undersigned unless such person requests that such Rights Certificate be registered in the name of and mailed to (complete only if Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): Please insert social security or other 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.____________
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights Represented by the Right Initial Rights Certificate.) To: ORAPHARMA, INCWGNB CORP. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person 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 toto (please type or print): Social Security or other identifying number: [ __________________ ] Name and Address: ____________________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name and Address: ___________________________________________________________________ (Please print name and address) ___________________________________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: _____________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., Social Security or a commercial bank or trust company having an office or correspondent in the United States.other identifying number:_______________________ Dated:____________________
Appears in 1 contract
Samples: Rights Agreement (WGNB Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered register holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAFROZEN FOOD EXPRESS INDUSTRIES, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person 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 print name and address) _________________________________________________________________ (Please insert social security or other identifying number) : ____________________________________ If such number of Rights shall not be all the Rights evidenced rights evidence by this Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_____________________________________ Dated: ______________, _______ ____________________________________ Signature Signature Guaranteed: ___________________________________________________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
Samples: Rights Agreement (Frozen Food Express Industries Inc)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights represented by this Rights Certificate.) To: ORAPHARMA, INC. FIRST BRANDS CORPORATION The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock or other securities, cash or other property issuable upon the exercise of such 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 or other securities be issued in the name of of, and delivered such cash or other property be paid to: Please insert social security or other identifying number: ________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ A new Rights Certificate evidencing the remaining balance, if any, of such Rights not hereby exercised shall be mailed to and registered in the name of the undersigned unless such person requests that such Rights Certificate be registered in the name of and mailed to (complete only if Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): Please insert social security or other 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.______________
Appears in 1 contract
Samples: Rights Agreement (First Brands Corp)
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAXXXX XX INDUSTRIES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) __________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ________________ _______________________ Signature Signature Guaranteed: ____________________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchangeDated: _______________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.19__ ______________________________ Signature
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: ORAPHARMATo XXXXXXX & XXXXX, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such 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 toof: Please insert social security or other identifying number ________________________________________________________________________________ (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 Right Certificate, a new Right Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, ______________________ _______________________ Signature Signature Guaranteed: __________________________________________________________ Signatures must be guaranteed by a member firm Dated as of a registered United States national securities exchange____________, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.____ ----------------------------------- Signature Signature Guaranteed:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, INC. UNIROYAL TECHNOLOGY CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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 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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: Please insert social security or other identifying number:_____________________________ Signatures must be guaranteed Dated: _________________ Signature Guaranteed:______________________ Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMA, GREATER NEW YORK BANCORP INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such 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) ____________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: ______________________________________ Signatures must be guaranteed Dated: ______________, 19__ ___________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMASCOTX XXXHNOLOGIES, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock Shares issuable upon the exercise of such the Rights (or Common Shares or such other securities of the Company or of any other person which 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 print name and address) _____________________________________________ (Please insert social security or other identifying number) number -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights 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 identifying number) number -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:__: _____________, _____ _______________________ ------------------------- Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.:
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAWild Oats Markets, INC. Inc.: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of such the Rights (or such other securities of the Company or of any other person which 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 _________________________________ (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 Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) ____________________________________________ (Please insert social security or other identifying number) Dated:_______________, __________________ _________________________________ Signature Signature Guaranteed: Dated:____________________ _____________________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.Signature
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Right Rights Certificate.) ToTO: ORAPHARMAHARVEST NATURAL RESOURCES, INC. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Rights Certificate to purchase the shares Preferred Shares (or such other securities of Series E Preferred Stock the Company) issuable upon the exercise of such Rights and requests that certificate for such Preferred Shares (or such other securities of the Company or of any other person which may be issuable upon the exercise of the RightsCompany) and requests that certificates for such shares be issued in the name of and delivered toof: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ (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 Right Rights Certificate, a new Right Rights 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 identifying number) Dated:_______________, ______________________ (Please insert social security or other identifying number) Dated: ____________________________ ___________________________________ _________________________________________ Signature Signature Signature(s) Guaranteed: ___________________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.39
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAPHYSICIAN RELIANCE NETWORK, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares number of Series E hundredths of a share of Preferred Stock issuable upon the exercise of such 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 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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered 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 print name and address) ________________________________________________________________________________ (________________________________________________________________________________ Please insert social security or other identifying number) Dated:______________________ Dated:__________, _____ ___________________________________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States._________________________________________________________
Appears in 1 contract
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: ORAPHARMAMATRIA HOLDING COMPANY, INC. : The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Series E Preferred Common Stock issuable upon the exercise of such 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) _______________________________________________________________________________ (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be be, registered in the name of and delivered to: Please insert social security or other identifying number _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ (Please insert social security or other identifying number) Dated:____________________, 20_____ _______________________ Signature Signature Guaranteed: ________________________ Signatures must be guaranteed Signature Signature Guaranteed: Certificate The undersigned hereby certifies by a member firm of a registered United States national securities exchange, a member of checking the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.appropriate boxes that:
Appears in 1 contract