Common use of PURCHASE FORM Clause in Contracts

PURCHASE FORM. The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ (Signature) Instructions for registration of Common Shares _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: ________________, 200___

Appears in 1 contract

Samples: Newtown Lane Marketing Inc

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PURCHASE FORM. The Undersigned hereby exercises (To be executed by the Warrant Certificate Holder if he desires to subscribe for and exercise the Warrant in whole or in part) To: COMBICHEM, INC. The undersigned, whose Social Security or other identifying number is ______________, hereby irrevocably elects the right of purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced represented by the within Warrant for, and to purchase thereunder, ____________________ shares of securities provided for therein and tenders payment herewith to the order of COMBICHEM, INC. in the amount of $___________ The undersigned requests that certificates for such shares be issued as follows: Name: --------------------------------------- Address: ------------------------------------- Deliver to: --------------------------------- Address: ------------------------------------ and, if said number of shares shall not be all the shares purchasable hereunder, that a new Warrant Certificate and herewith makes payment for the balance remaining of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of shares purchasable under the within Warrant Certificate will be registered in the name of of, and delivered to, the undersigned. undersigned at the address stated below Address: ------------------------------------ Dated: ________________ ____, _____ Signature. ------------------------------ (Signature must conform in all respects to the name of the Warrant Holder as specified on the face of the Warrant, without alteration, enlargement or any change whatsoever) (To be executed by the Warrant Holder if he desires to effect a transfer of the Warrant) FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers unto ______________________________ (Signature) Instructions for registration of Common Shares _________whose Social Security or other identification number is ______________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto _____________[residing/located] at ______________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within attached Warrant, and does hereby irrevocably constitute and appoint appoints __________________________ residing at ______________________________ attomey, the undersigned's attorney-in-fact to transfer such right said Warrant on the books of the Company Corporation, with full power of substitution in the premises. DATEDDated: ________________, 200_ ____, _____ In the presence of: ----------------------------------- ---------------------------------------- (Signature must conform in all respects to the name of the Warrant Holder as specified on the face of the Warrant, without alteration, enlargement or any change whatsoever).

Appears in 1 contract

Samples: Combichem Inc

PURCHASE FORM. The Undersigned undersigned hereby exercises irrevocably elects to exercise this Warrant, according to the Warrant Certificate terms and conditions hereof, to subscribe for and purchase the extent of purchasing shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate Stock and herewith hereby makes payment of $ in payment of the Exercise Priceexercise price thereof. Kindly issue certificates If the number of shares shall not be all of the shares purchasable under this Warrant, a new Warrant Certificate for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will balance remaining shall be registered issued in the name of the undersignedundersigned or its assignee as indicated on the Assignment Form. Dated: ____________________ INSTRUCTIONS FOR REGISTRATION OF STOCK Name: _______________________________________ (Signature) Instructions for registration of Common Shares _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint please typewrite or print in block letters) Address: ________________________________________________________________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATEDSignature: ________________, 200________________________________________________________________ Note: The signature must conform in all respects to name of holder as specified on the face of this Warrant Certificate Signature Guaranteed: ASSIGNMENT FORM FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers unto Name:--------------------------------------------------------------------------- (please typewrite or print in block letters) Address:------------------------------------------------------------------------ its right to purchase ----- shares of Common Stock represented by this Warrant and does hereby irrevocably constitute and appoint ---------Attorney, to transfer the same on the books of the Company, with full power of substitution in the premises. Dated:---------------------------------- ----------------------------------------- Signature:---------------------- Social Security or other number of holder Note: The signature must identifying conform in all respects to name of holder as specified on the face of this Warrant Certificate Signature Guaranteed:

Appears in 1 contract

Samples: Newscc Warrant Agreement (Smith Corona Corp)

PURCHASE FORM. The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. DatedDate: ________________________ The undersigned hereby irrevocably elects to exercise the within Warrant to the extent of purchasing _______ shares of Common Stock and hereby makes payment of _______ in payment of the actual exercise price thereof. ---------------- INSTRUCTIONS FOR REGISTRATION OF STOCK Name ________________________________ (SignaturePlease typewrite or print in block letters) Instructions for registration of Common Shares _________Address ______________________________ Name (Please print) __________Signature _____________________________ Social Security or Other Identifying Number: ASSIGNMENT FORM FOR VALUE RECEIVED, ______________ hereby sells, assigns and transfers unto Name _____________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please printtypewrite or print in block letters) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto _______________Address ____________________________ the right to purchase shares of the Common Stock represented by this Warrant to the extent of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, ______ shares as to which such right is exercisable and does hereby irrevocably constitute and appoint ___________ as attorney, to transfer the same on the books of the Company with full power of substitution in the premises. Date:_____________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: Signature ________________, 200_________ ************************************************************************ STOCK PURCHASE WARRANT To Purchase Common Stock of INTEGRAMED AMERICA, INC.

Appears in 1 contract

Samples: Integramed America Inc

PURCHASE FORM. (To be executed upon exercise of Warrant) The Undersigned undersigned hereby exercises the Warrant Certificate irrevocably elects to subscribe for and purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: ______________________________exercise _________ (Signature) Instructions Warrants evidenced by this Warrant Certificate, and herewith tenders in payment for registration such exercise payment of Common Shares the Exercise Price in full, in the form of a certified check payable to the order of Houston Biotechnology Incorporated in the amount of $_______________________________________ Name (Please print) _______________________________________ Social Security , all in accordance with the terms hereof. The undersigned requests that the Warrant Shares or Other Identifying Numberother securities receivable upon exercise be in fully registered form and registered in such name and delivered, together with any other property receivable upon exercise, as specified below. If said number of Warrants exercised is less than all of the Warrants evidenced hereby, the undersigned requests that a new Warrant Certificate representing the remaining Warrants evidenced hereby be issued and delivered as set forth below. Issue to: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint Name) ______________________________________________ attomey(Address, to transfer such right on the books of the Company with full power of substitution in the premises. DATEDincluding zip code) ______________________________________________ (Social security or other identifying number) Deliver to: ________________, 200______________________________ (Name) ______________________________________________ (Address, including zip code) Dated: ___________________ ____________________________________ (Insert social security or other identifying number of Holder) Signature: ____________________ NOTE: Signature must conform in all respects to name of Holder as specified on the face of this Warrant Certificate in every particular, without alteration or enlargement or any change whatsoever, unless this Warrant Certificate has been assigned.

Appears in 1 contract

Samples: Warrant Agreement (Medarex Inc)

PURCHASE FORM. To Be Executed Upon Exercise of Warrant The Undersigned undersigned record holder of this Warrant hereby exercises irrevocably elects to exercise the Warrant Certificate right to subscribe for and purchase shares of ________ Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, Shares evidenced by this Warrant, according to the within the Warrant Certificate terms and conditions thereof, and herewith makes payment of the Exercise Pricepurchase price in full. Kindly issue The undersigned requests that certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will such shares and warrants shall be registered issued in the name of the undersigned. set forth below: Dated: _________________________ NAME OF HOLDER: _______________________________________ (Signature) Instructions for registration of Common Shares _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. Signature: _________________________ Name: ______________________________ Title: _____________________________ [Print Name and Title of Signatory] Name and address to whom certificates are to be issued if different from above: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. Social Security Number or other identifying number of transferee: ______________________________________________________________________________ _______________________________________________________________________. If said number of shares and warrants shall not be all the right shares purchasable under this Warrant, the undersigned requests that a new Warrant for the unexercised portion shall be registered in the name of: ______________________________________________________________________________ ______________________________________________________________________________ Social Security Number or other identifying number:____________________________. FORM OF ASSIGNMENT ------------------ FOR VALUE RECEIVED, ___________________________ hereby sells, assigns and transfers to purchase shares of the Common Stock of the Company, $.001 par value _____________________________________ ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by Social Security or I.D. No. _______________________) the within Warrant, or that portion of this Warrant purchasable for ______________ common shares together with all rights, title and interest therein, and does hereby irrevocably constitute and appoint ______________________________________________ attomey_____________________________, attorney to transfer such right Warrant on the books register of the Company within named Company, with full power of substitution in the premisessubstitution. DATEDName of Holder: ________________, 200_______________________________________________ _____________________________________________________________________________. ________________________________________ Signature Name: __________________________________ Title: ________________________________ (Print Name and Title of Signatory Dated: ____________________________ Signature Guaranteed:

Appears in 1 contract

Samples: Cyberads Inc

PURCHASE FORM. (To be signed only upon exercise of Warrant) The Undersigned undersigned, the Holder of the foregoing Warrant, hereby exercises irrevocably elects to exercise the purchase rights represented by such Warrant Certificate for, and to subscribe for and purchase shares thereunder, ________________________ Shares of the Common StockStock of VIRAGEN, $.001 par value ("Common Shares")INC., of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of $____________ therefore, and requests that the Exercise Price. Kindly issue share certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered issued in the name of the undersigned. Dated: name(s) of, and delivered to ________________________________________________________________________________ whose address(es) is (Signatureare) Instructions for registration of Common Shares _____________________________________________________ Name (Please print) ________________________________________________________________________________ Social Security or Other Identifying Number: ________________________________________________________________________________ AddressDated: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant ------------------ --------------------------- (if anySignature) _______________________________________ --------------------------- Name (Please printPrint or Type) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City--------------------------- Address TRANSFER FORM (To be signed only upon transfer of the Warrant) For value received, State the undersigned hereby assigns and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer transfers unto ___________________________________________ the right to purchase shares of the Common Stock of the CompanyVIRAGEN, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced INC. represented by the within Warrantforegoing Warrant to the extent of ___________________________ Shares, and does hereby irrevocably constitute and appoint appoints ____________________________ attomey, attorney to transfer such right rights on the books of the Company with full power of substitution in the premises. DATED: ________________, 200__________ with full power of substitution in the premises. Dated: ------------------ --------------------------- (Signature) --------------------------- Name (Print or Type) --------------------------- Address

Appears in 1 contract

Samples: Viragen Inc

PURCHASE FORM. To Be Executed By The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common Stock, $.001 par value Holder To Exercise The Warrant In Whole Or In Part: To: NEOPROBE CORPORATION The undersigned ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ (Signature) Instructions for registration of Common Shares ____________________) Please insert Tax ID Number or other identifying number of Holder hereby irrevocably elects to exercise the right of purchase represented by the within Warrant for, and to purchase thereunder, ___________________ Name (Please print) _____________________________shares of Common Stock of Neoprobe Corporation in the amount of $__________ Social Security or Other Identifying NumberThe undersigned requests that certificates for those shares of Common Stock be issued as follows: Name:_______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint Address:_____________________________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: Deliver to:________________, 200__________________________ Address:_____________________________________________ Denominations:_______________________________________ and that, if the number of shares of Common Stock is not all the shares of Common Stock purchasable by exercise of the Warrant, that a new Warrant for the balance of the shares of Common Stock purchasable under the within Warrant be registered in the name of, and delivered to, the undersigned at the address stated below: Address:_____________________________________________ Date:________________________________________________ Signature:__________________________________ FORM OF ASSIGNMENT (To Be Executed Only Upon a Permitted Assignment) FOR VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers unto ____________________ the all of the undersigned's right, title and interest in the within Warrant. Signature:__________________________________ Signature Guaranteed:

Appears in 1 contract

Samples: Neoprobe Corp

PURCHASE FORM. To Be Executed By The Undersigned Warrant Holder To Exercise The Warrant In Whole Or In Part: To: NETMED, INC. The undersigned ( ) --------------------------------------------- Please insert Tax ID Number or other identifying number of Holder hereby exercises irrevocably elects to exercise the Warrant Certificate to subscribe for and right of purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced represented by the within the Warrant Certificate for, and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balanceto purchase thereunder, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ (Signature) Instructions for registration shares of Common Shares _____________________________Stock of NetMed, Inc. in the amount of $__________ Name (Please print) _______________________________________ Social Security or Other Identifying NumberThe undersigned requests that certificates for those shares of Common Stock be issued as follows: _______________________________________ Name: -------------------------------------- Address: _______________________________________ Street _______________________________________ City----------------------------------- Deliver to: -------------------------------- Address: ---------------------------------- and that, State and Zip Code HOLDER: PUBLIC SECURITIESif the number of shares of Common Stock is not all the shares of Common Stock purchasable by exercise of the Warrant, INC. By: ___________________________________ Title: President Instructions that a new Warrant for registration of certificate representing the unexercised balance of the shares of Common Stock purchasable under the within Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Numberbe registered in the name of, and delivered to, the undersigned at the address stated below: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code ----------------------------------- Date: -------------------------------------- Signature: ----------------------------------- FORM OF ASSIGNMENT (to be executed by the registered holder hereofTo Be Executed Only Upon An Assignment) FOR VALUE RECEIVED, ____________________________ does the undersigned hereby sellsells, assign assigns, and transfer transfers unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ____________________________ attomeyshares of Common Stock of NetMed, to transfer such right on Inc. evidenced by the books of the Company with full power of substitution in the premiseswithin Warrant. DATED: ________________, 200___Signature --------------------------------- Signature Guaranteed:

Appears in 1 contract

Samples: Netmed Inc

PURCHASE FORM. [Insert Details] The Undersigned undersigned hereby exercises irrevocably elects to exercise the right of purchase represented by the Warrant Certificate with respect to subscribe for and purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ Ordinary Shares of Itamar Medical Ltd. (Signature“Ordinary Shares”), at the Exercise Price per Ordinary Share set forth in the Warrant Agreement [on a net-exercise basis], and requests that certificates for the Ordinary Shares be issued and registered in Itamar's shareholders register, in the name of: (name and address must be printed or typewritten) Instructions for registration of Common Shares _______________________________________ Name (Please print) ___________and I.D. number ____________________________ Social Security or Other Identifying NumberAddress ____________________________ and, if the number of Ordinary Shares shall be less than the total number of Ordinary Shares that the Warrant-Holder is entitled to purchase pursuant to this Warrant, a new Warrant Certificate shall be registered for the balance of the Ordinary Shares in the name of the undersigned Warrant-Holder as below indicated and delivered to the address stated below. Dated: __________________ Name of Warrant-Holder: __________________________ Address: _____________________________ _____________________________ Street Signature: ____________________________ Note: The above signature must correspond with the name as written upon the face of this Warrant Certificate in every particular, without alteration or enlargement or any change whatever, unless this Warrant has been assigned. Signature Witnessed: __________________________________________ CityASSIGNMENT (To be signed only upon assignment of Warrants to Permitted Transferees) FOR VALUE RECEIVED, State the undersigned hereby sells, assigns and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___transfers this Warrant unto (name and I.D. number and address of assignee must be printed or typewritten) ________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _________________________________which is a Permitted Transferee of the Bank under the terms of the Warrant, hereby irrevocably constituting and appointing ______ Addressas Attorney-in-Fact to transfer said Warrant on the books of Itamar Medical Ltd., with full power of substitution in the premises. Dated: _______________________________________ Street _______________________________________ CitySignature of Registered Holder Note: The signature of this assignment must correspond with the name as it appears upon the face of the Warrant Certificate in every particular, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto without alteration or enlargement or any charge whatever. Signature Witnessed: ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: ________________, 200___

Appears in 1 contract

Samples: Warrant Agreement (Itamar Medical Ltd.)

PURCHASE FORM. The Undersigned undersigned hereby exercises irrevocably elects to exercise the Warrant represented by this Warrant Certificate to subscribe for and purchase the extent of _______ Units consisting of an aggregate of _____________ shares of Common Stock, par value $.001 par value ("per share, and _______ Warrants to purchase Common Shares")Stock at an initial exercise price of $2.50 per share, of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced by the within the Warrant Certificate and herewith hereby makes payment of the Exercise Price. Kindly issue certificates for the Common Shares $______________ in accordance with the instructions given below. The certificate for the unexercised balance, if any, payment of the within Warrant Certificate will be registered in the name of the undersignedactual exercise price thereof. DatedName: _______________________________________________________________ (SignaturePlease type or print in block letters) Instructions for registration of Common Shares Address:_____________________________________________________________ Name (Please printAddress for delivery of Stock Certificate) Social Security or Taxpayer Identification Number:______________________________________ Signature:___________________________________________________________ Social Security or Other Identifying Number: ASSIGNMENT FORM FOR VALUED RECEIVED, _____________________________ hereby sells, assigns and transfers unto__________________________________________________________________ (Please type or print in block letters) Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares Units of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced represented by this Warrant Certificate to the within Warrant, extent of ______________Units as to which such right is exercisable and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right the same on the books of the Company with full power of substitution in the premises. DATED___________________________________ Signature Dated: ________________, 200_________, 199_ Notice: The signature of this assignment must correspond with the name as it appears upon the face of this Warrant Certificate in every particular, without alteration or enlargement or any change whatever. SIGNATURE GUARANTEED: ___________________________________

Appears in 1 contract

Samples: Alfacell Corp

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PURCHASE FORM. [Insert Details] The Undersigned undersigned hereby exercises irrevocably elects to exercise the right of purchase represented by the Warrant Certificate with respect to subscribe for and purchase shares ____ Ordinary Shares of Common Stock, $.001 par value Itamar Medical Ltd. ("Common “Ordinary Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by at the within Exercise Price per Ordinary Share set forth in the Warrant Certificate Agreement [on a net-exercise basis], and herewith makes payment of the Exercise Price. Kindly issue requests that certificates for the Common Ordinary Shares be issued and registered in accordance with Itamar's shareholders register, in the instructions given below. The certificate name of: (name and address must be printed or typewritten) Name and I.D. number Address and, if the number of Ordinary Shares shall be less than the total number of Ordinary Shares that the Warrant-Holder is entitled to purchase pursuant to this Warrant, a new Warrant Certificate shall be registered for the unexercised balance, if any, balance of the within Warrant Certificate will be registered Ordinary Shares in the name of the undersignedundersigned Warrant-Holder as below indicated and delivered to the address stated below. Dated: _______________________________________ (Signature) Instructions for registration of Common Shares _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Numberof Warrant-Holder: _______________________________________ Address: _____________________________ _____________________________ Street Signature: ____________________________ Note: The above signature must correspond with the name as written upon the face of this Warrant Certificate in every particular, without alteration or enlargement or any change whatever, unless this Warrant has been assigned. Signature Witnessed: __________________________________________ CityASSIGNMENT (To be signed only upon assignment of Warrants to Permitted Transferees) FOR VALUE RECEIVED, State the undersigned hereby sells, assigns and Zip Code HOLDER: PUBLIC SECURITIEStransfers this Warrant unto (name and I.D. number and address of assignee must be printed or typewritten) which is a Permitted Transferee of the Bank under the terms of the Warrant, INC. By: _____________________________hereby irrevocably constituting and appointing ______ Titleas Attorney-in-Fact to transfer said Warrant on the books of Itamar Medical Ltd., with full power of substitution in the premises. Dated: President Instructions for registration Signature of certificate representing Registered Holder Note: The signature of this assignment must correspond with the unexercised balance name as it appears upon the face of the Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security Certificate in every particular, without alteration or Other Identifying Numberenlargement or any charge whatever. Signature Witnessed: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: ________________, 200___

Appears in 1 contract

Samples: Warrant Agreement (Itamar Medical Ltd.)

PURCHASE FORM. The Undersigned undersigned hereby exercises irrevocably elects to exercise the Warrant Certificate to subscribe for and right of purchase shares of Common Stock, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced represented by the within the Warrant Certificate and herewith makes payment in respect of ______________ of the Exercise Price. Kindly issue shares provided for therein, and requests that certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered issued in the name of the undersigned. Datedof: _________________________________________________________________ (SignaturePlease Print Name, Address and Taxpayer Identification Number) Instructions and, if said number of shares shall not be all the shares purchasable hereunder, that a new Warrant certificate for registration the balance of Common Shares the shares purchasable under the within Warrant be registered in the name of the unde rsigned Warrantholder or his Assignee as below indicated and delivered to the address stated below. The undersigned: / / elects to pay the full Warrant Price in cash or by certified or cashier's check or wire funds transfer / / elects "cashless exercise" pursuant to Section 5.2 of the Warrant "Current Value" for purposes of Cashless Exercise is: $__________ Number of shares issuable on Cashless Exercise is: ___________ shares / / elects simultaneous conversion pursuant to Section 5.4 of the Warrant Dated: ________________ _____________________________ Signature of Warrantholder The above signature must correspond with the name appearing upon the face of this Warrant in every particular, without alteration or enlargement or any change whatever. Name of Assignee, if any: ____________________________ (Please Print) ______________________________________________________ Name (Please printprint Name, Address and Taxpayer Identification Number) _______________________________________ Social Security or Other Identifying Number: _______________________________________ AddressSignature Guaranteed: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (Signature guarantee is required if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (certificates are to be executed registered in the name of any person other than the name written upon the face of the Warrant. Signature must be guaranteed by a commercial bank or trust company or a member firm of the registered holder hereofNew York Stock Exchange. (To be signed only upon assignment of Warrant) FOR VALUE RECEIVED, ____________________________ does the undersigned hereby sellsells, assign assigns and transfer transfers unto _________________________________________________________________ the right to purchase shares (Name and Address of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint Assignee Must Be Printed or Typewritten) _________________________________________________________________ attomey(Taxpayer Identification Number of Assignee) the within Warrant, hereby irrevocably constituting and appointing ____________________ Attorney to transfer such right said Warrant on the books of the Company Company, with full power of substitution in the premises. DATEDDated: ________________, 20019__ ______________________________ Signature of Registered Holder Signature Guaranteed: The above signature must correspond with the name appearing upon the face of this Warrant in every particular, without alteration or enlargement or any change whatever, and must be guaranteed by a commercial bank or trust company or a member firm of the New York Stock Exchange.

Appears in 1 contract

Samples: PHP Healthcare Corp

PURCHASE FORM. To Be Executed By The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common Stock, $.001 par value Holder To Exercise The Warrant In Whole Or In Part: To: NEOPROBE CORPORATION The undersigned ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ (Signature) Instructions for registration of Common Shares ____________________) Please insert Tax ID Number or other identifying number of Holder hereby irrevocably elects to exercise the right of purchase represented by the within Warrant for, and to purchase thereunder, ___________________ Name (Please print) _____________________________shares of Common Stock of Neoprobe Corporation in the amount of $__________ Social Security or Other Identifying NumberThe undersigned requests that certificates for those shares of Common Stock be issued as follows: Name:_______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint Address:__________________________________________ attomeyDeliver to:_______________________________________ Address:__________________________________________ Denominations:____________________________________ and that, to transfer such right on if the books number of shares of Common Stock is not all the shares of Common Stock purchasable by exercise of the Company with full power Warrant, that a new Warrant for the balance of substitution the shares of Common Stock purchasable under the within Warrant be registered in the premisesname of, and delivered to, the undersigned at the address stated below: Address:__________________________________________ Date:_____________________________________________ Signature:__________________ FORM OF ASSIGNMENT (To Be Executed Only Upon a Permitted Assignment) FOR VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers unto ____________________ the all of the undersigned's right, title and interest in the within Warrant. DATEDSignature_______________________________ Signature Guaranteed: ________________, 200_________________

Appears in 1 contract

Samples: Neoprobe Corp

PURCHASE FORM. The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common Stock, $.001 0.001 par value ("Common Shares"), of NEWTOWN LANE MARKETINGNova Oil, INCORPORATEDInc., a Delaware Nevada Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ ------------------------------------------------ (Signature) Instructions for registration of Common Shares _______________________________________ ------------------------------------------------ Name (Please print) _______________________________________ ------------------------------------------------ Social Security or Other Identifying Number: _______________________________________ ------------------------------------------------ Address: _______________________________________ ------------------------------------------------ Street _______________________________________ ------------------------------------------------ City, State and Zip Code HOLDERxxx Xxx Xxxx XXXXXX: PUBLIC SECURITIESXXXXXX XXXXXXXXXX, INCXXX. ByXx: ___________________________________ --------------------------------------- Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ ------------------------------------------------ Name (Please print) _______________________________________ ------------------------------------------------ Social Security or Other Identifying Number: _______________________________________ ------------------------------------------------ Address: _______________________________________ ------------------------------------------------ Street _______________________________________ ------------------------------------------------ City, State and Zip Code xxx Xxx Xxxx FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, _______________________________ does hereby sell, assign and transfer unto ________________unto___________________________ the right to purchase shares of the Common Stock of the Company, $.001 0.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATEDNova Oil, a Delaware Nevada Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ______________________________________ attomeyattorney, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: _______________________________ , 200____ ------------------------------------------------ (Signature) ------------------------------------------------ (Signature guaranteed)

Appears in 1 contract

Samples: Nova Oil Inc

PURCHASE FORM. The Undersigned undersigned hereby exercises irrevocably elects to exercise the Warrant represented by this Warrant Certificate to subscribe for and purchase the extent of _____________ shares of Common Stock, par value $.001 par value ("Common Shares")per share, of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced by the within the Warrant Certificate and herewith hereby makes payment of the Exercise Price. Kindly issue certificates for the Common Shares $______________ in accordance with the instructions given below. The certificate for the unexercised balance, if any, payment of the within Warrant Certificate will be registered in the name of the undersignedactual exercise price thereof. DatedName: _______________________________________________________________ (SignaturePlease type or print in block letters) Instructions for registration of Common Shares Address:_____________________________________________________________ Name (Please printAddress for delivery of Stock Certificate) Social Security or Taxpayer Identification Number:______________________________________ Signature:___________________________________________________________ Social Security or Other Identifying Number: ASSIGNMENT FORM FOR VALUED RECEIVED, _____________________________ hereby sells, assigns and transfers unto__________________________________________________________________ Address: (Please type or print in block letters) Address _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the CompanyStock, par value $.001 par value ("Common Shares")per share, of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced represented by this Warrant Certificate to the within Warrant, extent of ______________ shares as to which such right is exercisable and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right the same on the books of the Company with full power of substitution in the premises. DATED_______________________________ Signature Dated:_________________ , 199_ Notice: The signature of this assignment must correspond with the name as it appears upon the face of this Warrant Certificate in every particular, without alteration or enlargement or any change whatever. SIGNATURE GUARANTEED: ________________, 200_______________

Appears in 1 contract

Samples: Subscription Agreement (Alfacell Corp)

PURCHASE FORM. The Undersigned undersigned hereby exercises irrevocably elects to exercise the Warrant represented by this Warrant Certificate to subscribe for and purchase the extent of _____ shares of Common Stock, par value $.001 par value ("Common Shares")per share, of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced by the within the Warrant Certificate and herewith hereby makes payment of the Exercise Price. Kindly issue certificates for the Common Shares $_______ in accordance with the instructions given below. The certificate for the unexercised balance, if any, payment of the within Warrant Certificate will be registered in the name of the undersignedactual exercise price thereof. DatedName: _____________________________________________________________ (SignaturePlease type or print in block letters) Instructions for registration of Common Shares Address:_________________________________________________________ Name (Please printAddress for delivery of Stock Certificate) Social Security or Taxpayer Identification Number:__________________________________ Signature:_______________________________________________________ Social Security or Other Identifying Number: ASSIGNMENT FORM FOR VALUED RECEIVED, _____________________________ hereby sells, assigns and transfers unto ______________________________________ (Please type or print in block letters) Address: _______________________________________ Street _______________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. By: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the CompanyStock, par value $.001 par value ("Common Shares")per share, of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Alfacell Corporation, evidenced represented by this Warrant Certificate to the within Warrant, extent of __________ shares as to which such right is exercisable and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right the same on the books of the Company with full power of substitution in the premises. DATED-------------------------- Signature Dated: ________________-------------------- Notice: The signature of this assignment must correspond with the name as it appears upon the face of this Warrant Certificate in every particular, 200___without alteration or enlargement or any change whatever. SIGNATURE GUARANTEED: ------------------------- Schedule to July 2001 Private Placement Name Number of Units Purchase Price Eve Patton 166,667 $150,000 Mukul Garg 55,000 $ 50,000 Michael Pisani 30,000 $ 27,000

Appears in 1 contract

Samples: Purchase Agreement (Alfacell Corp)

PURCHASE FORM. To Be Executed By The Undersigned hereby exercises the Warrant Certificate to subscribe for and purchase shares of Common StockHolder To Exercise The Warrant In Whole Or In Part: To: Cragar Industries, $.001 par value Inc. The undersigned ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within the Warrant Certificate and herewith makes payment of the Exercise Price. Kindly issue certificates for the Common Shares in accordance with the instructions given below. The certificate for the unexercised balance, if any, of the within Warrant Certificate will be registered in the name of the undersigned. Dated: _______________________________________ (Signature) Instructions for registration Please insert Social Security or other identifying number of Common Shares ____________________Holder hereby irrevocably elects to exercise the right of purchase represented by the within Warrant for, and to purchase thereunder, ___________________ Name (Please print) shares of Common Stock of Cragar Industries, Inc. in the amount of $_______________________________________ Social Security or Other Identifying Number. The undersigned requests that certificates for those shares of Common Stock be issued as follows: ____Name:___________________________________ Address: :________________________________ Deliver to:_____________________________ Address:________________________________ and that, if the number of shares of Common Stock is not all the shares of Common Stock purchasable by exercise of the Warrant, that a new Warrant for the balance of the shares of Common Stock purchasable under the within Warrant be registered in the name of, and delivered to, the undersigned at the address stated below: Address:________________________________ Date:___________________________________ Street Signature:__________________________________ FOR VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers unto ______________________________ the right to purchase ________ shares of Common Stock of Cragar Industries, Inc. evidenced by the within Warrant. Signature___________________________________ City, State and Zip Code HOLDER: PUBLIC SECURITIES, INC. BySignature Guaranteed: ___________________________________ Title: President Instructions for registration of certificate representing the unexercised balance of Warrant (if any) _______________________________________ Name (Please print) _______________________________________ Social Security or Other Identifying Number: _______________________________________ Address: _______________________________________ Street _______________________________________ City, State and Zip Code FORM OF ASSIGNMENT (to be executed by the registered holder hereof) FOR VALUE RECEIVED, ____________________________ does hereby sell, assign and transfer unto ___________________________________________ the right to purchase shares of the Common Stock of the Company, $.001 par value ("Common Shares"), of NEWTOWN LANE MARKETING, INCORPORATED, a Delaware Corporation, evidenced by the within Warrant, and does hereby irrevocably constitute and appoint ____________________________ attomey, to transfer such right on the books of the Company with full power of substitution in the premises. DATED: ________________, 200___

Appears in 1 contract

Samples: Cragar Industries Inc /De

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