Common use of FORM OF ELECTION TO PURCHASE Clause in Contracts

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate) To: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 2 contracts

Samples: Rights Agreement (Culp Inc), Rights Agreement (Culp Inc)

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FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Rights represented by the Rights this Right Certificate.) ToTo Consolidated Graphics, Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be share(s) of Preferred Stock (or such other securities)be issued in the name of and delivered to: Please insert social security or other identifying numbername: ________________________________________________________________________________ (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 Right Certificate, a new Rights 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 insert social security or other identifying number) ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: ___________________, ______ ______. ____________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa member firm of a registered national securities exchange, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 a member of the National Association of Securities and Exchange Commission under Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the Securities Exchange Act of 1934, as amendedUnited States.

Appears in 2 contracts

Samples: Rights Agreement (Consolidated Graphics Inc /Tx/), Rights Agreement (Consolidated Graphics Inc /Tx/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo TWEETER HOME ENTERTAINMENT GROUP, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer 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) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11.1.2 of the Rights Agreement, 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 taxpayer number: Please insert social security or other identifying taxpayer number: ______________________________________________________________________________ Dated: ___________________, ______ ________________________________ ________________________________ ________________________________ ________________________________ (Please print name and address) Signature:______________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 2 contracts

Samples: Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc), Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. SELECT MEDICAL CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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 Rights Right Certificate, a new Rights 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:__________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa member firm of a registered United States national securities exchange, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 a member of the National Association of Securities and Exchange Commission under Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the Securities Exchange Act of 1934, as amended.United States. CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Select Medical Corp), Rights Agreement (Select Medical Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. Xxxx-Xxxxx Company: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: ______________________________ _Rights represented by this Right Certificate to purchase the shares of Common 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 (or other securities) 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 Right Certificate, a new Rights 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: ___________________The undersigned hereby certifies, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksmarking the appropriate boxes, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.that:

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 holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXOMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced represented by this Rights Right Certificate, a new Rights 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) ________________________________________________________________Date:______________ Dated: ___________________, ____19__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.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 Rights Right Certificate.) To: XXXXORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Series E Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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 Rights Right Certificate, a new Rights 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: ________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa member firm of a registered United States national securities exchange, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 a member of the National Association of Securities and Exchange Commission under Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the Securities Exchange Act of 1934, as amendedUnited States.

Appears in 2 contracts

Samples: Rights Agreement (Orapharma Inc), Rights Agreement (Orapharma Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. CD Radio Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Series B Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ____________ ___________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ___________________________________________________________________ Dated: __________________, 19__ _________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.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 by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate) To: XXXX, INC. Swift Energy Company The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Rights Certificate to purchase the shares Units of Series A Junior Participating Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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 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 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 Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ___________Dated:___________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 2 contracts

Samples: Rights Agreement (Swift Energy Co), Rights Agreement (Swift Energy Co)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the this Rights Certificate) To: XXXX, INC. MIM CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Rights Certificate to purchase the shares of Preferred Stock Units issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other Person 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) ______________________________________________________________________________ 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 address) If such number of Rights shall not be all of 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 addressname) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________________ (Please print address) Dated: ______________________________________, Signature: _______________________________________ (Sign exactly as your name appears on the other side of this Rights Certificate) Signature Signature GuaranteedGuarantee: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended._____________________________

Appears in 2 contracts

Samples: Rights Agreement (Mim Corp), Rights Agreement (Mim Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, ANCHOR BANCORP WISCONSIN INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Series A Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation 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) ___________________________________________________________ ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ___________________________________________________________ Dated: __________________, [19][20]__ ________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 2 contracts

Samples: Rights Agreement (Anchor Bancorp Wisconsin Inc), Rights Agreement (Anchor Bancorp Wisconsin Inc)

FORM OF ELECTION TO PURCHASE. (a) (To be executed if holder desires desire to exercise Rights represented by the Rights Certificate.) To: XXXXSEQUUS PHARMACEUTICALS, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ________:______________________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: ___________________, 19___. _______________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa bank, stockbrokersbroker, dealer, credit union or savings and loan associations, clearing agencies and credit unions with membership association or other entity that is a member in an approved good standing of a signature guarantee medallion program) pursuant to Rule 17Ad-15 of program approved by the Securities and Exchange Commission under Transfer Association, Inc. Certificate ----------- The undersigned hereby certifies by checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Sequus Pharmaceuticals Inc), Rights Agreement (Sequus Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Owens Corning: XXXX, INC. The undersigned hereby irrevocably herexx xxrevocably elects to exercise exer cise _______________ Rights represented by this Rights Certificate Right Cer tificate to purchase the shares of Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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: Please Xxease insert social security or other identifying number: ______________________________ ____________________number __________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced evi denced by this Rights Right Certificate, a new Rights 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: ______________________________ ____________________number __________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: _:__________________, ______ ________________[Form of Election to Purchase -- continued] __________________________ Signature (Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership conform in an approved signature guarantee medallion program) pursuant all respects to Rule 17Ad-15 name of holder as specified on the Securities and Exchange Commission under the Securities Exchange Act face of 1934, as amendedthis Right Certificate.)

Appears in 2 contracts

Samples: Rights Agreement (Owens Corning), Rights Agreement (Owens Corning)

FORM OF ELECTION TO PURCHASE. (TO BE EXECUTED IF HOLDER DESIRES TO EXERCISE THE RIGHT CERTIFICATE.) To be executed if holder desires to exercise Rights represented by the Rights Certificate) To: XXXXFAIRMARKET, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: ____________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, 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 taxpayer number: ____________ ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ________________________________________________________________________________ (Please print name and address) Dated: _________, __ ______________________________________________________________________________ Dated: ___________________, ______ __________________________________ Signature Signature Guaranteed: _________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.______________________

Appears in 2 contracts

Samples: Shareholder Rights Agreement (Fairmarket Inc), Shareholder Rights Agreement (Fairmarket Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateWarrants) ToTO: XXXXVION PHARMACEUTICALS, INC. The undersigned hereby irrevocably elects to exercise Warrants represented by this Warrant Certificate to purchase __________ shares of Common Stock issuable upon the exercise of such Warrants and requests that certificates for such shares of Common Stock be issued in the name of: ____________________________________ Rights represented Please insert social security, tax identification or other identifying number ___________________________ ___________________________ ___________________________ If such number of Warrants is not all the Warrants evidenced by this Rights Warrant Certificate, a new Warrant Certificate to purchase for the shares balance remaining of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other Person which may Warrants shall be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued registered in the name of and delivered to: Please insert social security security, tax identification or other identifying number: number ___________________________ ___________________________ ___________________________ (Please print name and address) Dated:________________________ ______________________________________________________________________________ Signature (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be Signature must conform in all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the respects to name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and addressholder as specified on the face of the Warrant Certificate) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 2 contracts

Samples: Warrant Agreement (Vion Pharmaceuticals Inc), Warrant Agreement (Vion Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO: XXXXDOVER DOWNS GAMING & ENTERTAINMENT, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: ______________________________ ________________________Rights represented by this Right Certificate to purchase the shares of Common Stock issuable upon the exercise of such Rights and requests that certificates for such share(s) be issued in the name: ______________________________________________________ (Please print name and address) ______________________________________________________________________________ Please insert social security or other tax identifying number If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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 tax identifying number _________________________________________ Dated: ________________ ____, 20_______ __________________________________________ Signature (Signature must conform in all respects to name/s of holder/s as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an "eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution" as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.. The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Dover Downs Gaming & Entertainment Inc), Rights Agreement (Dover Downs Gaming & Entertainment Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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) ______________________________________________________________________________ Dated: ___________________, ______ __Signature Signature Medallion Guaranteed: ________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution” as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.

Appears in 2 contracts

Samples: Rights Agreement (Pericom Semiconductor Corp), Rights Agreement (Pericom Semiconductor Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the this Rights Certificate) To: XXXXTHE BISYS GROUP, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Rights Certificate to purchase the shares of Preferred Company Common Stock issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other Person person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Company Common Stock (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) _______________________________________________________________________________ _______________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all of 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: __________________________ _______________________________________________________________________________ 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: print name) _______________________________________________________________________________ _______________________________________________________________________________ (Please print name and address) Dated: ___________________, ________________________________ Signature: ____________________________ Dated(Sign exactly as your name appears on the other side of this Rights Certificate) Signature Guarantee: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 2 contracts

Samples: Rights Agreement (Bisys Group Inc), Rights Agreement (Bisys Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. The undersigned hereby irrevocably elects to exercise To ______________ _: The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, __20____ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 2 contracts

Samples: Rights Agreement (Forgent Networks Inc), Rights Agreement (Forgent Networks Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) ToTO: XXXX, VERADIGM INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 2 contracts

Samples: Rights Agreement (Veradigm Inc.), Rights Agreement (Veradigm Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO: XXXX, FXCM INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares share(s) be issued in the name of and delivered tofollowing name: 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 Right Certificate, a new Rights 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) ______________________________________________________________________________ Dated: ___________________________ Dated: ___________ ___, ______ ______________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by a participant in a Medallion Signature Guarantee Program at a guarantee level acceptable to the Corporation’s Rights Agent. The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not, and never have been, beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the Rights Agreement). ______________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.Signature

Appears in 2 contracts

Samples: Rights Agreement (FXCM Inc.), Rights Agreement (FXCM Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo ANDOVER BANCORP, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer 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: ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, 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 taxpayer number: _____________________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: _________, __ _________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.____________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Andover Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented Represented by the Initial Rights Certificate) To: XXXX, INCWGNB CORP. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 to (please type or print): Social Security or other identifying number: [ __________________ ] Name and Address: ___________________________________________________________________ ______________________________________________________________________________ (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 numberName and Address: ___________________________________________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ___________________Social Security or other identifying number:_______________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.Dated:____________________

Appears in 1 contract

Samples: Rights Agreement (WGNB Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXiPayment, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Series A Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Corporation 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) ________________________________________________________________________________ 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: ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to:_________________ Please insert social security or other identifying number:____________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: _______________, 200_ ________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Ipayment Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXxXXxX*s, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares or portion thereof of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: 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 ______________________________________________________________________________ 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 print name and address) Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (dELiAs, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo TWEETER HOME ENTERTAINMENT GROUP, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer 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) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11.1.2 of the Rights Agreement, 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 taxpayer number: Please insert social security or other identifying taxpayer number: ______________________________________________________________________________ Dated: ___________________, ______ ___________________________________ ___________________________________ ___________________________________ ___________________________________ (Please print name and address) Signature:_________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. _________________________ The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Shenandoah Telecommunications Co/Va/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented Represented by the Second Rights Certificate) To: XXXX, INCWGNB CORP. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 to (please type or print): Social Security or other identifying number: [ _________________ ] Name and Address: ___________________________________________________________________ ______________________________________________________________________________ (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 numberName and Address: ___________________________________________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ DatedSocial Security or other identifying number: ___________________, ______ __________________________________________ Signature Signature GuaranteedDated: Signatures must be guaranteed ____________________ Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (WGNB Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXUNITED DOMINION REALTY TRUST, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Series C Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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: ______________________________ 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: ______________________________ number ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated(Please print name and address) 1 Date: ___________________, ______ __________________________________________ -------------------------------- Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

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 Rights Certificate.) To: XXXX, INC. __________________________ The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person 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 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 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 Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Daktronics Inc /Sd/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo WARRXX XXXCORP, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: ______________________________ ______________________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ______________________________________________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights 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 taxpayer number: ______________________________ ______________________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ______________________________________________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed _______________ CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Warren Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, OPTIKA INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please insert social security or other identifying number: ___________). Dated ___________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate ----------- The undersigned hereby certifies by an eligible guarantor institution checking the appropriate boxes in (including banks, stockbrokers, savings 1) and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program(2) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.that:

Appears in 1 contract

Samples: Rights Agreement (Optika Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. LOJACK CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or Common Stock or such other securities of the Corporation 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: ___________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: ___________number ___________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ____________________________________________________________________________ Dated: ----------------------------- Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Lojack Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate) To: XXXX, INC. CTPartners Executive Search Inc. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Rights Certificate to purchase the shares Units of Series A Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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 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 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 Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ___________Dated:___________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Ctpartners Executive Search Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, GREATER NEW YORK BANCORP INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: ______________________________ __________________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: ______________________________ __________________number ____________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ____________________________________________________________ Dated: ______________, 19__ ___________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Greater New York Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Urstadt Bxxxxx Properties Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise _________________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares (or other securities) issuable upon the exercise of the such Rights (or such other securities of the 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 evidenced by this Rights Right Certificate, a new Rights 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) ______________________________________________________________________________ Dated: _____________________, __________ __________________________________________ Signature (Signatures to the foregoing Election to Purchase and the following certificate must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Urstadt Biddle Properties Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateTO BE EXECUTED IF HOLDER DESIRES TO EXERCISE RIGHTS REPRESENTED BY THE RIGHTS CERTIFICATE.) To: XXXX, INC. Mellon Investor Services LLC The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number: 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 ______________________ ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.Certificate

Appears in 1 contract

Samples: Rights Agreement (Centene Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. ADVANTA CORP.: The undersigned hereby irrevocably elects to exercise ______________ Class [A][B] Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: ____________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: ___________number ___________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: :___________________, ___ ,____ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Advanta Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo BROOKTROUT TECHNOLOGY, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: __________________ _____________ ______________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights 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 taxpayer number: _____________________ __________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: ___________, ____ _________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.______________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Brooktrout Technology Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo INTERSTATE HOTELS CORPORATION: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer 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: ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, 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 taxpayer number:_____________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated:_________________ _________________________ Signature Signature Guaranteed: Signatures must be guaranteed :_________________________ The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Interstate Hotels Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. TREDEGAR CORPORATION: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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: ______________________________ _______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: ______________________________ _______number _______________________________________________________________________ (Please print name and address) ______________________________________________________________________________ DatedDate: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Tredegar Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXROMAC INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person that may be issuable upon the exercise of the Rights) 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 represented by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Form of Reverse Side of Rights Certificate -- continued Please insert social security or other identifying number: _____________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: ____________________ , ____ ___ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Romac International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXGLASSBRIDGE ENTERPRISES, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: number ______________________________________________________ Please print name and address _________________ _______________________________________________________________________________________________ (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: number _____________________________________________________ Please print name and address __________ _______________________________________________________________________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Medallion Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: 382 Rights Agreement (GlassBridge Enterprises, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the this Rights Certificate) ToTO: XXXX, INCST. FRANXXX XXXITAL CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock Shares (or other securities, cash or property) issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of and delivered toof: Please insert social security or other identifying numberprint name and address: ______________________________________ ______________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Please insert social security, taxpayer identification or other identifying number: ______________________________________ If such number of Rights shall not be all the Rights evidenced represented by this Rights Certificate, a new Rights Certificate for the balance of such remaining unexercised Rights shall be registered in the name of and delivered to: Please insert social security or other identifying numberprint name and address: ______________________________________ ______________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ DatedPlease insert social security, taxpayer identification or other identifying number: ___________________, ___________________ Dated: __________________ , ____ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksEligible Guarantor Institution, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.. Signature Guaranteed:___________________________________________________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (St Francis Capital Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INCCPI CORP. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Series A Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Corporation 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) ________________________________________________________________________________ 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: ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: ________________ Please insert social security or other identifying number: ________________ ________________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: _______________, 200_ ______________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cpi Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXAMERICAN BANKERS INSURANCE GROUP, INC. .: The undersigned hereby irrevocably elects to exercise ________________ __________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities securities, cash or other assets of the Corporation 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 such cash or other assets) 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) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: Dated:___________________________, 19___ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (American Bankers Insurance Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXRAWLINGS SPORTING GOODS COMPANY, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer identification 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 taxpayer identification number: _______________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Rawlings Sporting Goods Co Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo CRITICARE SYSTEMS, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of one one-hundredth Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of and delivered toof: Please insert social security or other identifying number: 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: ___________________________________ 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) ______________________________________________________________________________ Dated: ___________________, ______ ________________ Dated:________________, 20__ ________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa member firm of a registered national securities exchange, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 a member of the National Association of Securities and Exchange Commission under Form of Reverse Side of Right Certificate -- continued Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the Securities Exchange Act of 1934, United States. ------------------------------------------------------------------------------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as amended.defined in the Rights Agreement). _______________________________

Appears in 1 contract

Samples: Rights Agreement (Criticare Systems Inc /De/)

FORM OF ELECTION TO PURCHASE. (TO BE EXECUTED IF HOLDER DESIRES TO EXERCISE THE RIGHT CERTIFICATE.) To be executed if holder desires to exercise Rights represented by the Rights Certificate) ToGENZYME TRANSGENICS CORPORATION: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number: ------------------- ------------------------------------------------------------------------ ------------------------------------------------------------------------ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, 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 taxpayer number: -------------------- ----------------------------------------------------------------------- ----------------------------------------------------------------------- (Please print name and address) Dated: _________, __ ____________________________________________ ____________________________________________ Signature Signature Guaranteed: ___________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Shareholder Rights Agreement (Genzyme Transgenics Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXSOFTWARE PUBLISHING CORPORATION HOLDINGS, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of and delivered toof: 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: ___________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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) _______________________________________________________________________________ Dated(Please print name and address) Please insert social security or other identifying number: ___________________ Dated: ________________, ____ ___ _____________________________________________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa bank, stockbrokersstock broker, savings and loan associations, clearing agencies and association or credit unions union with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, . _______________________________________________________________________________ The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as amendeddefined in the Rights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Software Publishing Corp Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the this Rights Certificate) To: XXXXDUKE REALTY INVESTMENTS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Rights Certificate to purchase the shares of Preferred Stock Units issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other Person 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) ___________________________________________________________________________ ___________________________________________________________________________ (Please print address) If such number of Rights shall not be all of 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) ______________________________________________________________________________ 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: print name) ___________________________________________________________________________ ______________________________________________________________________________ (Please print name and address) Dated: ____________, ______________________ Signature:_____________________________________________ Dated: ___________________, ______ ______________________(Sign exactly as your name appears on the other side of this Rights Certificate) Signature Guarantee:____________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE ----------- The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Duke Realty Investments Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXFrontier Airlines, INC. Inc.: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: _______________________________ Please insert social security or other identifying numbernumber If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: _______________________________ Please insert social security or other identifying number _______________________________ ________________________________________________ _______________________________ (Please print name and address) ____________________________________________________________________Dated:__________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: __________________________, ____ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.Signature

Appears in 1 contract

Samples: Rights Agreement (Frontier Airlines Inc /Co/)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate) To: XXXXTO MILLERS AMERICAN GROUP, INC. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock (or other securities) issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares share(s) be issued in the name of and delivered tofollowing name: 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 Right Certificate, a new Rights 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) Dated: ___________________________________. ___________________________________________ Dated: ___________________, ______ __________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Medallion Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Millers Mutual Fire Insurance Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Warrant Certificate) To). TO: XXXXMEDIA LOGIC, INC. CC: XXXXXX CAPITAL GROUP, LTD. 0000 Xxxxxx Xxxxxx, Xxxxx 000 Xxx Xxxxxx, Xxxxxxxxxx 00000 Attn: Xxxxxxx Xxxxxx Fax: (000) 000-0000 The undersigned hereby irrevocably elects to exercise _________Warrants represented by this Warrant Certificate to purchase _____ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) Warrants and requests that certificates for such shares be issued in the name of and delivered toof: (Please insert social security security, tax identification or other identifying number: _) _____________________________ __________________________________________________ _____________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights Warrants shall not be all the Rights Warrants evidenced by this Rights Warrant Certificate, a new Rights Warrant Certificate for the balance remaining of such Rights Warrants shall be registered in the name of and delivered to: Please insert social security security, tax identification or other identifying number: _number _____________________________ __________________________________________________ _____________________________ (Please print name and address) Dated: ________________________, ______________________________________________________ Dated: ___________________, ______ __________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Warrant Certificate) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Warrant Agreement (Media Logic Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXENTERPRISE BANCORP, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or Common Stock or such other securities securities, cash or other property of the Corporation Company or of any other Person which person that may be issuable or otherwise deliverable 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 print name and address) ________________________________________________________________________________ Dated: ___________________, __________________ __________________________________________ Signature Medallion Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Renewal Rights Agreement (Enterprise Bancorp Inc /Ma/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) ToTO: XXXX, WHG RESORTS & CASINOS INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation WHG Resorts & Casinos Inc. 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: 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: number ______________________________ ______________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: :_______________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (WHG Resorts & Casinos Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. Southwest Water Company The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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: ______________________________ __________________number ____________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ _________________________ Signature Signature Guaranteed: ________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an "eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution" as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Southwest Water Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. MERIDIAN POINT REALTY TRUST VIII COMPANY The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number: _______ __________________ _______ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: _______ __________________ _______ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.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 holder desires to exercise Rights represented by the Rights CertificateRIGHTS CERTIFICATE) To: XXXX, INCRENEX CORP. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the 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 evidenced by this Rights Certificate, a new 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: :___________________, ______ __________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this RIGHTS CERTIFICATE) Signature Guaranteed: Signatures must be guaranteed The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Renex Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INCOCTEL CORP. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 print social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ____________________________________________ (Please print social security or other identifying number) Dated:_______________, _____ ________________ Signature Signature Guaranteed:___________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Octel Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise any or all of the Rights represented by the this Rights Certificate.) To: XXXX, INC. SPRINT CORPORATION: The undersigned hereby irrevocably elects to exercise _________________________ (____)Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: taxpayer identification 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: taxpayer identification number ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Sprint Corp)

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FORM OF ELECTION TO PURCHASE. (To be executed if the holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXCREE, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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: ___________________, ____20__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed ________________________ Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cree Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXInterface, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other 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: 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: ______________________________ _________________________________number _____________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ____________________, _______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.Exhibit C

Appears in 1 contract

Samples: Rights Agreement (Interface Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXTo FIRST MID-ILLINOIS BANCSHARES, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which may be issuable or such other assets which may be deliverable upon the exercise of the Rights) and requests that certificates for any such shares or 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 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 Medallion Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (First Mid Illinois Bancshares Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXSOFTWARE PUBLISHING CORPORATION HOLDINGS, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of of: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and delivered to: 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 Rights Right Certificate, a new Rights 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 an eligible guarantor institution (including banksa bank, stockbrokersstock broker, savings and loan associations, clearing agencies and association or credit unions union with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, . -------------------------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as amendeddefined in the Rights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Software Publishing Corp Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXLOWE'S COMPANIES, INC. The .: Xxe undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Series A Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ ___________ ______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ Dated(Please print name and address) Date: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Lowes Companies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate) To: XXXXKEY TECHNOLOGY, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: :____________________________ _______________________________________________________________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ Dated: :___________________, _________ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Key Technology Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate) ToTo ChaseMellon Shareholder Services L.L.C.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock (or other securities) issuable upon the exercise of the such Rights (or such other securities of the 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 numberName: ______________________________ ______________________________________________________________________________ (Please print name and address) Address: _______________________________________________ Social Security or Taxpayer I.D. No.: ______________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and an delivered to: Please insert social security or other identifying numberName: ______________________________ ______________________________________________________________________________ (Please print name and address) Address: _______________________________________________ Social Security or Taxpayer I.D. No.: ______________________________________________ Dated: ___________________, ______ __________________________________________ Signature (Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership conform in an approved signature guarantee medallion program) pursuant all respects to Rule 17Ad-15 name of holder as specified on the Securities and Exchange Commission under the Securities Exchange Act face of 1934, as amended.this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (Coeur D Alene Mines Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate) To: XXXX, UNI-MARTS INC. The undersigned hereby irrevocably elects to exercise __________________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Fractional Share issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other Person which may be issuable upon the exercise of the such Rights) and requests that certificates for such the shares of Common Stock be issued in the name of and delivered toof: Please insert social security or other identifying number: number _______________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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: number _______________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: ____________________________ Signatures must be guaranteed by an eligible guarantor institution (including banksa bank, stockbrokersstockbroker, savings and loan associations, clearing agencies and association or credit unions union with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Uni Marts Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. Maxar Technologies Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the shares of Series A Preferred Stock issuable upon the exercise of the such Rights (or such other securities or property of the Corporation Company or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares stock (or such other securities or property of the Company or of any other Person which may be issuable upon the exercise of the Rights) be issued in the name of and delivered (or to: Please insert social security or other identifying number: ______________________________ _________________, as the case may be): _____________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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) ______________________________________________________________________________ Dated: ___________________, ______ ____________Signature Signature Medallion Guaranteed: ______________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution” as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended., which is a member of a recognized Medallion Signature Guarantee Program. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Tax Benefit Preservation Plan (Maxar Technologies Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXxxxxxx, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 of: ______________________________________________________________________________ (Please print name and delivered to: 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed (by a member firm of The New York Stock Exchange or a commercial bank or trust company having an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership office or correspondent in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of New York City): Certificate The undersigned hereby certifies by checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Wellman Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXWOLVERINE WORLD WIDE, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ _________________ ___________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ____19__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Wolverine World Wide Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Series B Rights Certificate.) To: XXXXFRUIT OF THE LOOM, INC. The undersigned hereby irrevocably elects to exercise ______________ Series B Rights represented by this Series B Rights Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Series B Rights (or such other securities of the Corporation Company or of any other Person person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of and delivered to: Please insert social security or other identifying numberof: ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Series B Rights shall not be all the Series B Rights evidenced by this Series B Rights Certificate, a new Series B Rights Certificate for the balance remaining of such Series B 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 Guaranteed: __________________________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Eligible Guarantor Institution as defined by SEC Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended(17 C.F.R. 240.17-Ad-15).

Appears in 1 contract

Samples: Rights Agreement (Fruit of the Loom Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. CLECO CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of $25 Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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: 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: number ______________________________ ______________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: ___________________, ____20__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by a member firm of a national securities exchange, a member of the National Association of Securities Dealers, Inc., a commercial bank or trust company having an office or correspondent in the United States or another eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) as defined pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended).

Appears in 1 contract

Samples: Rights Agreement (Cleco Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise any or all of the Rights represented by the Rights this Right Certificate) ToTo PDL BioPharma, Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ( ) of the Rights represented by this Right Certificate to purchase the shares of the Common Stock of the Company, or other securities or property issuable upon the exercise of said number of Rights pursuant to the Rights Agreement. The undersigned hereby requests that a certificate for any such securities and any such property be issued in the name of and delivered to: ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: ____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (Please print Name, address and social security or other identifying number of issuee) The undersigned hereby further requests that if said number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the remaining balance of such Rights be issued in the name of and address) 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) ______________________________________________________________________________ (Name, address and social security or other identifying number of issuee) Dated: ___________________, ______ __________________________________________ Signature (Signature) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution Form of Reverse Side of Right Certificate (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.continued)

Appears in 1 contract

Samples: Rights Agreement (PDL Biopharma, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, INC. QUAKER FABRIC CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: ______________________________ ______________________________________________________________________________ number (Please print name and address) ______________________________________________________________________________ (Please print name and address of transferee) If such number of Rights specified above shall not be all the Rights evidenced by this Rights Right Certificate, the Rights Agent shall place an appropriate notation on this Right Certificate with respect to those Rights exercised or a new Rights 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: ______________________________ ______________________________________________________________________________ number (Please print name and address) ______________________________________________________________________________ (Please print name and address of transferee) Dated: ___________________, ____19__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Quaker Fabric Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. The undersigned hereby irrevocably elects to exercise :_________________ The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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 Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ Dated: Please insert social security or other identifying number:___________________, ______ _____________________________________________________ Dated: ____________ __, ____ ----------------------------- Signature Signature Guaranteed: Signatures must be guaranteed Certificate ----------- The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Eldertrust)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXMicrel, INC. Incorporated The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation 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 numberof: ______________________________ ______________________________________________________________________________ (Please print name and address) _________________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights 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: number ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Dated: Signature Signature Medallion Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution” as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Micrel Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo MEDFORD BANCORP, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights 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 taxpayer number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ _____________________________________________________________ Dated: _____________, _____ _______________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.____________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Medford Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXXXXXXX ASSOCIATES, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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: _________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Gilbert Associates Inc/New)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Synagro Technologies, Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities or property of the Corporation 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) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: Please insert social security or other identifying number:___________________, ______ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated:____________________ ________________________________________ Signature Signature Guaranteed: Signatures NOTICE The signatures to the foregoing Form of Election To Purchase must be guaranteed by an eligible guarantor institution (including bankscorrespond to the name as written upon the face of this Right Certificate in every particular, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amendedwithout alteration or enlargement or any change whatsoever.

Appears in 1 contract

Samples: Rights Agreement (Synagro Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. The undersigned hereby irrevocably elects to exercise _______________ The undersigned hereby irrevocably elects to exercise______ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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 Guaranteed: Signatures must be guaranteed 60 CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cybercash Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) ToTO: XXXXXxxxxxxxx-UTI Energy, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ______________, _____, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Patterson Uti Energy Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. ASARCO CYPRUS INCORPORATED: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: 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: number ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: _______________, ____ _________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Asarco Cyprus Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXX, HOLLINGER INTERNATIONAL INC. The undersigned hereby irrevocably elects irrevoxxxxx xxxcts to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Series Z Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ____20__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE ----------- The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Hollinger International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXLIBERTY TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 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 Rights Certificate, a new Rights Certificate for the balance of such Rights shall be he 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: __________________ __, _____199_/200_ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed 50 Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Liberty Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXHyseq, INC. Inc. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation 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: 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 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 toDated: Please insert social security or other identifying number: ______________________________ _________________________________________________ Signature Signature Guaranteed: ______________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an "eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership institution" as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission promulgated under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Hyseq Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo CELL THERAPEUTICS, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number: _________________________ __________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, 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 taxpayer number: ______________________________ __________________________ (Please print name and address) Dated: _________________________________________________, ____ (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 numberSignature Medallion Signature Guaranteed: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Shareholder Rights Agreement (Cell Therapeutics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo ALBANY MOLECULAR RESEARCH, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: ________________________________ _______________________________________________________________________________________ (Please print name and address) _______________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights 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 taxpayer number: ________________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ (Please print name and address) Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: ______________________________ Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership a participant in an approved signature the Medallion Signature Guarantee Program at a guarantee medallion program) pursuant level acceptable to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amendedCompany’s Transfer Agent.

Appears in 1 contract

Samples: Shareholder Rights Agreement (Albany Molecular Research Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTO PHOTRONICS, INC. .: The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of and delivered toof: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (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 Right Certificate, a new Rights 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 insert Social Security or other identifying number:_________________________________________________________. Please print name and address: ______________________________________________________________________________ (Please print name and address.) ______________________________________________________________________________ DatedDate: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksbank, stockbrokers, stock broker or savings and loan associations, clearing agencies and credit unions association with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.). Date:

Appears in 1 contract

Samples: Section 382 Rights Agreement (Photronics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise any or all of the Rights represented by the Rights this Right Certificate) ToTo Northstar Neuroscience, Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ( ) of the Rights represented by this Right Certificate to purchase the shares of the Common Stock of the Company, or other securities or property issuable upon the exercise of said number of Rights pursuant to the Rights Agreement. The undersigned hereby requests that a certificate for any such securities and any such property be issued in the name of and delivered to: ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: _______________________________________________________________________________________________ ____________________________________________________________________________________________________________ (Please print Name, address and social security or other identifying number of issuee) The undersigned hereby further requests that if said number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the remaining balance of such Rights be issued in the name of and address) 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) ______________________________________________________________________________ (Name, address and social security or other identifying number of issuee) Dated: ___________________, ______ ___________________________________, _______ Signature (Signature) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution Form of Reverse Side of Right Certificate (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.continued)

Appears in 1 contract

Samples: Rights Agreement (Northstar Neuroscience, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate.) ToTo Manatron, Inc.: XXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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) ______________________________________________________________________________ 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 remaining 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) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed CERTIFICATE The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Manatron Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by the this Rights Certificate) To: XXXX, INC. FIRST BRANDS CORPORATION The undersigned hereby irrevocably elects to exercise __________________ 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 such Rights (or such other securities of the Corporation 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) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a A new Rights Certificate for evidencing the balance 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 delivered to: 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: ________________________ _______ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

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 Rights Certificate) To: XXXXFURNITURE BRANDS INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Rights Certificate to purchase the shares Units of Series B Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other Person which person 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 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 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 Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ___________Dated:___________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Furniture Brands International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO: XXXX, INC. The undersigned hereby irrevocably elects to exercise ________________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred the Common Stock issuable upon the exercise of the such Rights (or such other securities of the 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: 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 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.:

Appears in 1 contract

Samples: Rights Agreement (Nathans Famous Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateCertificate other than pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXFIBERSTARS, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares one one-thousandths of a share of Preferred Stock (or such other securities of the Company or any other Person) issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying numberof: ___________________________________________________________________________________________ (Please insert social security or other identifying number) ___________________________________________________________________________________________ (Please print name and address) ___________________________________________________________________________________________ If such number of Rights shall not be all applicable, the Rights evidenced by this Rights CertificateCertificate indicating the balance, a new Rights Certificate for the balance if any, of such Rights which may still be exercised pursuant to Section 11(a)(ii) of the Rights Agreement shall be returned to the undersigned unless such Person requests that the Rights Certificate 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 (complete only if Rights Certificate is to be registered in a name other than the undersigned) ___________________________________________________________________________________________ (Please print name and address) ___________________________________________________________________________________________ Dated: ___________________, ______ , 20__________________. ________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksEligible Guarantor Institution, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership as defined in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Fiberstars Inc /Ca/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXX, INC. NUI CORPORATION The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: ______________________________ ______________________________________________________________________________ (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 print name and address) Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ____20__ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Nui Holding Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate) To: XXXX, INC. AmeriSource Health Corporation The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the 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 insert social security or other identifying number: ______________________________ Rights represented by this Right Certificate to purchase the Common Shares issuable upon the exercise of such Rights (or such other securities of the Company or of any other person which may be issuable upon exercise of the Rights) and requests that certificates for such securities 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 Right Certificate, a new Rights 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:_______________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banksa member firm of a registered United States national securities exchange, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 a member of the National Association of Securities and Exchange Commission under Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the Securities Exchange Act of 1934, as amendedUnited States.

Appears in 1 contract

Samples: Rights Agreement (Amerisource Health Corp/De)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXAlbexxxxx'x, INCXxc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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) 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) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ __________________________________________ Signature Signature Guaranteed: Signatures must be guaranteed 75 Certificate The undersigned hereby certifies by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of checking the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Albertsons Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXTo BAY APARTMENT COMMUNITIES, INC. .: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 taxpayer number: ______________ _________________ ______________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights 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 taxpayer number: ______________ _________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: ___________________, ______ ________________________________________________________________________________ Dated: _________________ _________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended._______________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Bay Apartment Communities Inc)

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