Please issue the Sample Clauses

Please issue the certificate for shares of Common Stock in the name of, and pay any cash for any fractional share to: Print or type name Social Security or other Identifying Number Street Address City State Zip Code

Please issue the certificate for shares of Common Stock in the name of, and pay any cash for any fractional share to: -------------------------------------------------------------------------------- Print or type name -------------------------------------------------------------------------------- Social Security or other Identifying Number -------------------------------------------------------------------------------- Street Address -------------------------------------------------------------------------------- City State Zip Code

Please issue the. Common Stock into which the Warrant is being exercised to the Holder, or for its benefit, as follows:  Check here if requesting delivery as a certificate to the following name and to the following address: Issue to: Address: _________________________________________ Telephone Number: ________________________________ Email Address:  Check here if requesting delivery by Deposit/Withdrawal at Custodian as follows: DTC Participant: DTC Number: _________________________________________ Account Number: ________________________________ Authorization: By: Title: Dated: Account Number (if electronic book entry transfer): Transaction Code Number (if electronic book entry transfer): Date: _______________ __, ______ Name of Registered Holder By: Name: Title: ACKNOWLEDGMENT The Company hereby acknowledges this Exercise Notice and hereby directs American Stock Transfer & Trust Company, LLC to issue the above indicated number of shares of Common Stock in accordance with the Transfer Agent Instructions dated December 16, 2020 from the Company and acknowledged and agreed to by American Stock Transfer & Trust Company, LLC. Palisade Bio, Inc. By:________________________________ Name: Title: