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: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Gibson Greetings Inc), Rights Agreement (Gibson Greetings Inc)

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FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. INTERPHASE CORPORATION 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ---------------------------- -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ---------------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ --------------------- ----- ----------------------------------------- Signature Signature Guaranteed: Certificate ___________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

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

FORM OF ELECTION TO PURCHASE. (a) (To be executed if holder desires desire to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSSEQUUS 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 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 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: Certificate ______________________________________________ Dated: ___________________, 19___. _______________________ Signature Signature Guaranteed: Signatures must be guaranteed by a bank, broker, dealer, credit union or savings association or other entity that is a member in good standing of a signature guarantee medallion program approved by the Securities Transfer Association, Inc. Certificate ----------- The undersigned hereby certifies by checking the 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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) number: ----------------------------------- ---------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ 19 ---------------- -- ------------------------------ Signature Signature Guaranteed: Certificate ___________ ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

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

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INCAMSURG CORP. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) ________________________________________________________________ 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) number: ---------------------- Dated:___________________, ____ ___________________________________ : -------------------------- ------------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

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

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSNEOSE TECHNOLOGIES, INC. .: 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 Common Shares or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _______________________________________________________________________________ (Please print name and address) Dated:___________________, ____________________________________________________________ ___________________________________ Signature Signature Guaranteed: Certificate _____________________________________________ Dated: , 19 -------------- --- -------------------------- Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Neose Technologies Inc), Rights Agreement (Neose Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSINTEGRATED DEFENSE TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: ------------------------------------------------- ------------------------------------------------- ------------------------------------------------- (Please print name and address) ------------------------------------------------- (Please insert social security or other identifying number ________________________________________________________________ (Please print name and addressnumber) ________________________________________________________________ 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 addressnumber) Dated:_: __________________, ____ ___________________________________ ------------------------------ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Integrated Defense Technologies Inc), Rights Agreement (Integrated Defense Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSSCIENTIFIC-ATLANTA, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: ------------------------------------------------------------ (Please print name and address) ------------------------------------------------------------ Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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) number:-------------------------------- ------------------------------------------------------------ Dated:___________________: ------------------, ____ ___________________________________ 19-- ---------------------------------- Signature Signature Guaranteed: Guaranteed:-------------------------- Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Scientific Atlanta Inc), Rights Agreement (Scientific Atlanta 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: XXXXXX GREETINGS, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ___________________ ____________________________________________________________________________ (Please print name and address) ____________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ___________________ ____________________________________________________________________________ (Please print name and address) Dated:___________________, _________________________________________________________ ___________________________________ Signature Signature Guaranteed: Certificate __________________________________________ Dated: ----------------------------- Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Lojack Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXXX GREETINGSVINA TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock (or such other securities of the Company) issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered 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 -------------------------------------------------------------------------------- The Rights Certificate for indicating the balance 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 the undersigned requests that the Rights Certificate be registered in the name of and delivered to: -------------------------------------------------------------------------------- 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: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Vina Technologies 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: XXXXXX GREETINGSTo GPU, 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 Company or of any other person which may be Person) issuable upon the exercise of the Rights) 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 -------------------------------------------------------------------------------- The Rights Certificate for indicating the balance balances, if any, of such Rights which may still be exercised pursuant to each of Section 11(a)(ii) and Section 13 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 _________________________________________________________________ (complete only if Rights Certificate is to be registered in a name other than the undersigned) -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ 19 -------------------- -- ------------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Pennsylvania Electric Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. UNITED STATES STEEL CORPORATION: The undersigned hereby irrevocably elects to exercise _____________________________ Rights exercise____________Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security ----------------------------- or other identifying number --------------------------- ________________________________________________________________________________ (Please print name and address) Dated:___________________, _____________________________________________________________ ___________________________________ Signature Signature Guaranteed: Certificate ______________________________________________ Dated:_________,_______ ________________________ Signature Signature Guaranteed: Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Usx Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSAmerican Securities Transfer & Trust, 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 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: Reverse Side of Rights Certificate ___________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Centennial Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. HYPERION SOFTWARE CORPORATION: The undersigned hereby irrevocably elects to exercise ______________________exercise_______ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------------------------------- -------------------------------------------------------------------------- (Please print name and address) Dated:___________________, ____ ___________________________________ : --------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Imrs Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSTo ANIKA 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 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 ________________________________________________________________ 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 number _________________________________________________________________ taxpayer number: --------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ ------------------ --- ----------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:-----------------------

Appears in 1 contract

Samples: Shareholder Rights Agreement (Anika Therapeutics 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: XXXXXX GREETINGSFIBERSTARS, INC. The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the 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 and requests that certificates for such shares be issued in the name of: ___________________________________________________________________________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number 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 (complete only if Rights Certificate is to be registered in a name other than the undersigned) ___________________________________________________________________________________________ (Please print name and address) Dated:___________________, ____ _____________________________________________________________________ Signature Signature GuaranteedDated: Certificate ________________________, 20____. ________________________ The undersigned hereby certifies Signature Signature Guaranteed: Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Fiberstars Inc /Ca/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGS, INC. Accuride Corporation 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 Company or of any other person 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 number_______________________________________ ____________________________________________________________ (Please print name and address) Dated:___________________, ____ ______________________________________ Signature Signature GuaranteedDated: Certificate ____________________________ Signature Signature Medallion Guaranteed: _____________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended, which is a member of a recognized Medallion Signature Guarantee Program. The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Accuride Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. Optical Sensors Incorporated The undersigned irrevocably 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 Common Shares or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : ----------------------------------------- ----------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Optical Sensors Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. R&B FALCON 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 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:____________________________________________________________ ____________________________________________________________ Dated: _______________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (R&b Falcon Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. MARKETSPAN 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 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 deliverable 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" meeting the requirements of the Rights Agent, which requirements include membership or participation in the Security Transfer Agent Medallion Program ("STAMP") or such other "signature guarantee program" as may be determined by the Rights Agent in addition to, or in substitution for, STAMP, all in accordance with the Securities Exchange Act of 1934, as amended. Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Marketspan Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. DOMINION BRIDGE CORPORATION The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Series One Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ ------------------------------------------------------------------------ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ------------------------------------------------------------------------ ------------------------------------------------------------------------ Dated: , ____________________________________________________________,_____ (Please print name and address) Dated:___________________, ____ ___________________________________ ----------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Dominion Bridge Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. AMERICAN RETIREMENT CORPORATION The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) ____________________________________________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 _____________________________________________number: ____________________ (Please print name and address) Dated:___________________, ____ ___________________________________ : --------------------------- ------------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:-------------------------------------------------------------------------------

Appears in 1 contract

Samples: Rights Agreement (American Retirement Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Rights evidenced by this Rights Certificate.) To: XXXXXX GREETINGS, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units (or such other securities which may be issuable upon the exercise of the Rights) be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ number: --------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and 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 _________________________________________________________________ number: --------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and name) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking ------------------------------------- Signature: --------------------------------------------------------------------- (Sign exactly as your name appears on the appropriate boxes that:other side of this Rights Certificate)

Appears in 1 contract

Samples: Rights Agreement (Mim Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGS, INC. THE XXXXXXXX AND XXXXXXXX COMPANY The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Right Certificate to purchase the shares of Preferred Stock Units issuable upon the exercise of the Rights (or such other securities of the Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: ----------------------------------- (Please print name and address) ----------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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 of such Rights shall be registered in the name of and delivered to: ----------------------------------- (Please print name and address) ----------------------------------- Please insert social security or other identifying number ________________________________________________________number: --------------- Dated: _________ (Please print name and address) Dated:___________________, __200__ ___________________________________ ---------------------------- Signature Signature Medallion Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Reynolds & Reynolds Co)

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: XXXXXX GREETINGS, 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 Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ______________________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) 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: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:Certificate

Appears in 1 contract

Samples: Rights Agreement (Centene Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGS, INC. ImClone Systems Incorporated 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares securities be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ---------------------- -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this 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: Certificate ___________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Imclone Systems Inc/De)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. CORAM HEALTHCARE CORPORATION The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Series X Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ----------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ----------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ -------------- ------- ---------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Coram Healthcare Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) ToTO: XXXXXX GREETINGSBIG FLOWER HOLDINGS, INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : ----------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Big Flower Holding Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSDYCOM INDUSTRIES, 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 Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: -------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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 ______________________________________________number: -------------------------- Dated: ___________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ Signatures must be guaranteed by a member firm of a registered national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States. CERTIFICATE ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Dycom Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. THE EARTHGRAINS 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ ------------------------------------------------------------------------------ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) ------------------------------------------------------------------------------ ------------------------------------------------------------------------------ Dated:___________________: ---------------, ____ ___________________________________ ---- --------------------------------------- Signature Signature Guaranteed: Certificate ___________ ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Earthgrains Co /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSAmerican Securities Transfer & Trust, 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 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: Reverse Side of Rights Certificate ___________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Centennial Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. CENTEX 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 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 Certification 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 a participant in a Securities Transfer Association recognized signature guarantee program. Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Centex Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSTo ANIKA 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 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 ______________________________________________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 number ____________________________________________taxpayer number: _____________________ ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:------------------- ---- -------------------------- Signature

Appears in 1 contract

Samples: Shareholder Rights Agreement (Anika Therapeutics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:___: ________________, ____ ___________________________________ --------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Marsh Supermarkets Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSSOFTWARE 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 Company 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) ___________________________________________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 print name and address) Please insert social security or other identifying number ____________________________________________number: _____________________ (Please print name and address) Dated:___: ________________, ____ ___________________________________ -------------------------------------------------------------------------------- Signature Signature Guaranteed: Certificate ___________ Signatures must be guaranteed by an eligible guarantor institution (a bank, stock broker, savings and loan association or credit union with membership in an approved signature guarantee program) pursuant to Rule 17Ad-15 of the Securities Exchange Act of 1934. -------------------------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by checking this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the appropriate boxes that: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: XXXXXX GREETINGSAGRITOPE, INC. The undersigned hereby irrevocably elects to exercise _____________________________ ---------- Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ 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: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Agritope Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSUNITED 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 Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ ------------------------------------------------------------------------------ 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:____Date: _______________, ____ ___________________________________ -------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (United Dominion Realty Trust Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSJMAR TECHNOLOGIES, 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 or property of the Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (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 _________________________________number: _______________________________ (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) Dated:___________________, ____ ___________________________________ : -------------------------- --------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies --------------------------------- Signatures must be guaranteed by checking an "eligible guarantor institution" as defined in Rule 17Ad-15 promulgated under the appropriate boxes that:Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Jmar Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSTo 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 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 ___________________________________________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 number ____________________________________________taxpayer number: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:________: ___________, ____ ___________________________________ Signature Signature Guaranteed: Certificate _______________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Warren Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSCRAFTMADE INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company 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 addressPLEASE 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 addressPLEASE PRINT NAME AND ADDRESS) ------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : --------------------- ------------------------------------------ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Craftmade International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSXxXxxxxxx International, INC. 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares securities be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ___________________________________________________________ (Please 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 _________________________________________________________________ (Please print name and address) Dated:___________________, __19__ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (McDermott International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO NEW PLAN REALTY TRUST: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Right Certificate to purchase the shares Shares of Preferred Stock Beneficial Interest issuable upon the exercise of the 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 share(s) be issued in the name of and delivered toname: 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:____: _______________, __19__ ___________________________________ ------------------------------------ Signature (Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:fact of this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (New Plan Realty Trust)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. First Chicago Trust Company of New York The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ---------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ---------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ -------------- ---- ------------------------------ Signature Signature Guaranteed: Reverse Side of Rights Certificate ___________ Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (BJS Wholesale Club 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.) To: XXXXXX GREETINGS, 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 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, 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) Dated:delivered to: ___________________, ____ __________________________________________________________ Signature Signature Guaranteed: Certificate (Name, address and social security or other identifying number of issuee) Dated:________________________ (Signature) Signature Guaranteed: Form of Reverse Side of Right Certificate (continued) CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Virage Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateWarrant certificate.) To: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights Warrants represented by this Rights Warrant Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) Warrants 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 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 or other identifying number _________________________________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) Dated:: ___________________, __19__ ___________________________________ ------------------------------------------- Signature (Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Warrant Certificate)

Appears in 1 contract

Samples: New Century Financial Corp

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSSIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares number of hundredths of a share of Series One Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) _____________________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 number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: 55 Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Signature Inns Inc/In)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. Fleet National Bank The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number _______________________________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate _____________________________________________ (Please print name and address) _______________________________________________________________________________ Dated: -------------- ----------------------------- Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Eclipsys Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo SUMMIT PROPERTIES INC.: XXXXXX GREETINGS, 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 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 ________________________________________________________________ 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 number _________________________________________________________________ taxpayer number: ---------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : ---------- -------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:-----------------------

Appears in 1 contract

Samples: Shareholder Rights Agreement (Summit Properties Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXXX GREETINGSTo APPLIED MOLECULAR EVOLUTION, INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock (or such other securities of the Company) issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered 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 ---------------------------------------------------------------- The Rights Certificate for indicating the balance 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: (Complete only if Rights Certificate 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: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:Signature

Appears in 1 contract

Samples: Rights Agreement (Applied Molecular Evolution Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Marathon Rights represented by the Marathon Rights Certificate.) To: XXXXXX GREETINGS, INC. USX CORPORATION: The undersigned hereby irrevocably elects to exercise _____________________________ Marathon Rights represented by this Marathon Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Marathon Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Marathon 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 Marathon Rights shall not be all the Marathon Rights evidenced by this Marathon Rights Certificate, a new Marathon Rights Certificate for the balance of such Marathon Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ --------------------------------------------------------------------------- (Please print name and address) --------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ ------------ ----- --------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Marathon Oil Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented repre- sented by the Rights Certificate.) To: XXXXXX GREETINGS, LENDINGTREE INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ______________________________________________________________________________ (Please print name and address) Dated:___________________, ___________________________________________________________ ______________________________________________________________________________ Dated: _______________, _____ __________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Lendingtree Inc

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXXX GREETINGS, INC. S3 INCORPORATED The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock (or such other securities of the Company) issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered 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 ------------------------------------------------------------------------------- The Rights Certificate for indicating the balance 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 _________________________________________________________________ (complete only if Rights Certificate is to be registered in a name other than the undersigned) ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- Dated:_______: ____________, ____ ___________________________________ . ------------------------------------ Signature Signature Guaranteed: Certificate ___________ 44 CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (S3 Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSCOVENTRY HEALTH CARE, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock Common Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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 number: Dated:_________________________, [________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ ]. ------------------------------------------ Signature Signature Guaranteed: ------------------------------------------------------------------------------ Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Coventry Health Care Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSAlloy, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) Dated:___________________, ____ ___________________________________ Signature : --------------------------- Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Alloy Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, O'CHARLEY'S INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) ___________________________________________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 ____________________________________________number: _____________________ (Please print name and address) Dated:___________________, ____ ___________________________________ : ------------------------- -------------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (O Charleys Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented repre sented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. XxxxXxxxxxxx.Xxx Inc.: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:____: _______________, ____ ___________________________________ -------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Homeservices Com Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) ToTO: XXXXXX GREETINGSHARVEST NATURAL RESOURCES, 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 Shares (or such other securities of the Company or of any other person which may be Company) issuable upon the exercise of the Rights) such Rights and requests that certificates certificate for such shares Preferred Shares (or other securities of the Company) 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 addressnumber) ________________________________________________________________ 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 print name and address) -------------------------------------------------------------------------------- (Please insert social security or other identifying number _________________________________________________________________ (Please print name and addressnumber) Dated:___________________, ____ ___________________________________ : ---------------------------- ----------------------------------- ----------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:Signature

Appears in 1 contract

Samples: Rights Agreement (Harvest Natural Resources Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSTo 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 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 ______________________________________________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 number ____________________________________________taxpayer number: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:________: ___________, ____ _________________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:____

Appears in 1 contract

Samples: Shareholder Rights Agreement (Andover Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGS, INC. TO BFC FINANCIAL 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 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 ________________________________________________________________ (Rights represented by this Right Certificate to purchase the Series A Preferred Stock or other securities 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) _________________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: Certificate ___________ The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (BFC Financial Corp)

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: XXXXXX GREETINGSTo AGOURON 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 Shares (or such other securities of the Company or of any other person which may be Person) issuable upon the exercise of the Rights) Rights and requests that certificates for such shares be issued in the name of: ---------------------------------------------------------------- (Please insert social security or other identifying number) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- If applicable, the Rights Certificate indicating 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 (complete only if Rights Certificate is to be registered in a name other than the undersigned) ---------------------------------------------------------------- (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 number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ . ---------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Agouron Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSTHE WARNACO GROUP, 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 Company or of any other person which or other property that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: ---------------------------------------------------- (Please print name and address) ---------------------------------------------------- ---------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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) number: ----------------------- Dated:___________________: , ____ ___________________________________ 200 ----- -- - ------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Warnaco Group Inc /De/)

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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 THE RIGHT CERTIFICATE.) ToTo GENZYME TRANSGENICS CORPORATION: XXXXXX GREETINGS, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying 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 number 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 toSignature Signature Guaranteed: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

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 CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXXX GREETINGSTo GPU, INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Common Stock (or such other securities of the Company) issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered 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 -------------------------------------------------------------------------------- The Rights Certificate for indicating the balance balances, if any, of such Rights which may still be exercised pursuant to each of Section 11(a)(ii) and Section 13 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 _________________________________________________________________ (complete only if Rights Certificate is to be registered in a name other than the undersigned) -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ 19 -------------------- ---- ------------------------------------ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Pennsylvania Electric Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSMarvel Enterprises, 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 or property of the Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered toof: Please 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 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 Guaranteed: Certificate ___________ -------------------------- NY/296241.3 -1- Signatures must be guaranteed by an "eligible guarantor institution" as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended. The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Marvel Enterprises Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO _____________________: XXXXXX GREETINGS, 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 Company 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 ________________________________________________________________ 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:______: _____________, __199__ ___________________________________ ------------------------------- Signature (Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (Donnkenny Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Rights Certificate.) ToTO ZymeTx, Inc.: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights 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 Company 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 following 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 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 _____________number:___________________________________________________ ------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ If such number -------------------------------------------------------------------------------- Dated: ------------------- --------------------------------------------- Signature (Signature must conform in all respects to name of Rights shall not be all holder as specified on the Rights evidenced by face of this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Zymetx Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. American Stock Transfer & Trust Company 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate _____________________________________________ (Please print name and address) _______________________________________________________________________________ Dated: ________________ ____________________________ Signature Signature Guaranteed: Reverse Side of Rights Certificate Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (American Superconductor Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSAlloy, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) Dated:___________________, ____ ___________________________________ Signature : -------------------------- Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Alloy Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSTHOMXX XXXUP, 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 Company Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and addressPLEASE 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 addressPLEASE PRINT NAME AND ADDRESS) -------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : -------------------------- -------------------------------------------- Signature Signature Guaranteed: Certificate ___________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Thomas Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Xxxx Xxxxxxx Financial Services, Inc.: XXXXXX GREETINGS, 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 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 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:___________________, ____ _________[Form of Election to Purchase -- continued] __________________________ Signature (Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Right Certificate.)

Appears in 1 contract

Samples: Rights Agreement (Hancock John Financial Services Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. FORWARD AIR CORPORATION The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) ___________________________________________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 ____________________________________________number: _____________________ (Please print name and address) Dated:___________________, ____ ___________________________________ : ---------------------------- ---------------------------------------- Signature Signature Guaranteed: -------------------------------------------------------------------------------- 45 Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Forward Air Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. SOUTHTRUST 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 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 Identifying number _________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ 20 . ------------------- ---- --- ------------------------------------- Signature Signature Guaranteed: Certificate ___________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Southtrust Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, ARMCO INC. The undersigned hereby irrevocably elects to exercise _____________________________ --------------- Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ----------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ ----------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ ----------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ ---------------- ----- -------------------------------- Signature Signature Guaranteed: - 7 - Certificate ___________ ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Armco Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGSTo BELLAVISTA CAPITAL, INC. .: 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying 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 number 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: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Bellavista Capital Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSLOWX'X XXMPANIES, INC. .: The 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 Company or of any other 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: ______________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number number: ________________________________ ______________________________________________________________________________ (Please print name and address) Dated:______________________________________________________________________________ (Please print name and address) Date: _______________, ____ ___________________________________ Signature Signature Guaranteed: 55 Certificate ___________ The undersigned hereby certifies by checking the 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 Right Certificate.) ToTo COURIER CORPORATION: XXXXXX GREETINGS, 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 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 ______________________________________________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 number ____________________________________________taxpayer number: _____________________ ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ ------------ ------ -------------------------------- Signature Signature Guaranteed: Certificate ___________ -------------------- CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Courier Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSTHOMXX XXXUP, 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 Company Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ ------------------------------------------------------------------------------- (Please print name and addressPLEASE 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 addressPLEASE PRINT NAME AND ADDRESS) -------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : --------------------- ------------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Thomas Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. [Company Name] 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- (Please insert social security or other identifying number) If such number of Rights shall not be all the Rights evidenced by this 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:___________________: , ____ ___________________________________ 19 -------------- -- ---------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes thatGuarantee:

Appears in 1 contract

Samples: Rights Agreement (Quest Education Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by the this Rights Certificate.) To: XXXXXX GREETINGS, INC. EXIDE 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares or other securities be issued in the name of of, and delivered such cash or other property be paid to: Please insert social security or other identifying number 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 number: ________________________ ______________________________________________________________________________ (Please print name and address) Dated:___________________, ____ ________________________________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Exide Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, UNION PACIFIC RESOURCES GROUP INC. .: 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 Common Shares or such other securities of the Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please 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: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Union Pacific Resources Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. Xxxxx Limited 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 such Rights (or such other securities of the Company or of any other person which or other property that may be issuable upon the exercise of the such Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: ---------------------------------------------------- (Please print name and address) ---------------------------------------------------- ---------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) _________________________________________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 ____________________________________number: _____________________________ (Please print name and address) Dated:___________________, ____ _________________________: __________ __, 200_ --------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Bunge LTD)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSSERVICE MERCHANDISE COMPANY, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units 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) ________________________________________________________________ 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) number: --------------------- Dated:___________________, ____ ___________________________________ : ---------------------- -------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:--------------------------------------------------------------------------------

Appears in 1 contract

Samples: Rights Agreement (Service Merchandise Co Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSDRIL-QUIP, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which 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:_______: ____________, __199__ ___________________________________ ---------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking a member firm of a national securities exchange, a member of the appropriate boxes that: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 (as defined pursuant to Rule 17Ad-15 under the Securities Exchange Act of 1934, as amended).

Appears in 1 contract

Samples: Rights Agreement (Dril-Quip Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. First Community Corporation The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Units of Preferred Stock Stock, issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares 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 insert social security or other identifying number ________________________________________________________________________________ (Please print name and address) Dated:___________________, ____ __________________________________________________________ Signature Signature GuaranteedPlease insert social security or other identifying number: Certificate _____________________ Dated: , 20 ------------------ --- ------------------------------------ Signature Signature Guaranteed: ----------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (First Community Corp /Tn/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) To: XXXXXX GREETINGS, INC. LABORATORIES 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 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 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 _________________________________________________________________ number: ------------------------------------------------ ----------------------------------------------------------------------------- (Please print name and address) Dated:___________________: , ____ ___________________________________ ---------------------- ---- --------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Abbott Laboratories)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSCOACHMEN INDUSTRIES, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock Common Shares issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered 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 _________________________________________________________________ ------------------------------------------------------------------------------ (Please print name and address) Dated:------------------------------------------------------------------------------ ------------------------------------------------------------------------------ Dated ___________________, _____ ------------------------- Signature Signature Guaranteed: ____________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Coachmen Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number __________________________________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate _____________________________________________ (Please print name and address) _______________________________________________________________________________ Dated: _____________ --------------------------------- Signature Signature Guaranteed: Reverse Side of Rights Certificate Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Penwest Pharmaceuticals Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. ------------------------------ The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------ Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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) number: ------------------------------ ------------------------------------------------ Dated:___________________: , ____ ___________________________________ --------------- ---- --------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Informax 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: XXXXXX GREETINGS, 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 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 ________________________________________________________________ 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 number _________________________________________________________________ taxpayer number: ----------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : -------------- -------------------------------------------- Signature Signature Guaranteed: Certificate ___________ ---------------------------------------- B-7 CERTIFICATE ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Interstate Hotels Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSFREEMARKETS, 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 Company Corporation or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series A Preferred Stock 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) ________________________________________________________________ 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) number: ------------------------ Dated:___________________, ____ ___________________________________ : ------------------- ---------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Freemarkets 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: XXXXXX GREETINGSVINA TECHNOLOGIES, 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 issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be Person) issuable upon the exercise of the Rights) 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 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 _________________________________________________________________ (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: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Vina Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. ------------------------------ The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ________________________________________________________________ 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) number: --------------------------------------- -------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ -------------------- ---- --------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Sunrise Assisted Living 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 Trident Microsystems, Inc.: XXXXXX GREETINGS, INC. The undersigned hereby irrevocably elects to exercise _______________ (_______________ ) of the Rights represented by this Rights Right Certificate to purchase the shares of Preferred the Common Stock of the Company, or other securities or property issuable upon the exercise of said number of Rights pursuant to the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and Agreement. The undersigned hereby requests that certificates a certificate for any such shares securities and any such property be issued in the name of and delivered to: Please insert -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (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 delivered to: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Name, address and social security or other identifying number of issuee) Dated:__________________, 19_____________ __________________________________ (Please print name and addressSignature) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Trident Microsystems Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGS, INC. PG&E CORPORATION 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 Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: -------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------- Please insert social security or other identifying number ________________________________________________________________ (Please print name and address) ____________________________________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 _____________________________________number: ____________________________ (Please print name and address) Dated:___________________: , ____ ___________________________________ -------------------- ---- -------- ------------------------ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Pg&e Corp)

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: XXXXXX GREETINGSTo AGOURON 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 Shares (or such other securities of the Company or of any other person which may be Person) issuable upon the exercise of the Rights) Rights and requests that certificates for such shares be issued in the name of: ---------------------------------------------------------------- (Please insert social security or other identifying number) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- If applicable, the Rights Certificate indicating 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 (complete only if Rights Certificate is to be registered in a name other than the undersigned) ---------------------------------------------------------------- (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 number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ _. __________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Agouron Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo ZOLL MEDICAL CORPORATION: XXXXXX GREETINGS, 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 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 ______________________________________________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 number ____________________________________________taxpayer number: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_______: ____________, ____ ___________________________________ Signature Signature Guaranteed: Certificate ___________ CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Zoll Medical Corporation)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: XXXXXX GREETINGSTo AGOURON PHARMACEUTICALS, INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares Common Shares (or such other securities of Preferred Stock the Company) issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: ---------------------------------------------------------------- (Please insert social security or other identifying number) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- The Rights Certificate shall be returned to the undersigned (indicating the balance, if any, of such Rights which may still be exercised pursuant to Section 11(a)(ii) of the Rights Agreement) 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 (complete only if Rights Certificate is to be registered in a name other than the undersigned) ---------------------------------------------------------------- (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 number _________________________________________________________________ (Please print name and address) Dated:___________________, ____ ___________________________________ . ---------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Agouron Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by the this Rights Certificate.) To: XXXXXX GREETINGSATMI, INC. Inc. 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 Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares or other securities be issued in the name of of, and delivered such cash or other property be paid to: Please insert social security or other identifying number 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 name of the undersigned): Please insert social security or other identifying number number: ________________________ __________________________________________________________________________ (Please print name and address) Dated:___________________, ____ ____________________________________________________ Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Atmi Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSINPUT/OUTPUT, INC. The undersigned hereby irrevocably elects to exercise _____________________________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company 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 addressPLEASE 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 addressPLEASE PRINT NAME AND ADDRESS) ------------------------------------------------------------------------------- Dated:___________________, ____ ___________________________________ : ---------------------------- ------------------------------------- Signature Signature Guaranteed: Certificate ___________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Input Output Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: XXXXXX GREETINGSCELLULAR COMMUNICATIONS OF PUERTO RICO, INC. .: The undersigned hereby irrevocably elects to exercise _____________________________ --------------------- Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: Please insert social security or other identifying number ________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) ________________________________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _________________________________________________________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:___________________: , ____ ___________________________________ 19 -------- -- ---------------------------------------- Signature Signature Guaranteed: Certificate ___________ ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Corecomm Inc)

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