Common use of SUBSCRIPTION FORM Clause in Contracts

SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________

Appears in 2 contracts

Samples: Engagement Agreement (Hinto Energy, Inc), Engagement Agreement (Hinto Energy, Inc)

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SUBSCRIPTION FORM. To be Be Executed by the Registered Holder of this Warrant if such Holder Desires in Order to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ________________Registered Holder hereby irrevocably elects to exercise ___________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase Warrants represented by this Warrant forcertificate, and to purchase thereunderthe securities issuable upon the exercise of such Warrants, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock securities shall be issued as follows: Name: __________________________________________________________________________ Address: _________________in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER ______________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ______________________________________________________ [please print or type name and address] and be delivered to ______________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________________________________________ ______________________________________________________ ______________________________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. _________________________________________ (Name of NASD Member) Dated: X ___________________________________ ___________________________________ ___________________________________ Address ___________________________________ Taxpayer Identification Number

Appears in 1 contract

Samples: Bion Environmental Technologies Inc

SUBSCRIPTION FORM. To be Executed signed only upon exercise of Warrant. The undersigned, the holder of the within Warrant, hereby irrevocably elects to exercise the purchase right represented by the Holder of this such Warrant if such Holder Desires for, and to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Propertiespurchase thereunder, Inc. (the "Company") The undersigned ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock of Cafe Odyssey, Inc. (the "Common StockShares") provided for therein to which such Warrant relates and tenders herewith makes payment herewith to the order of the Company in the amount of $_______________ therefor in cash, such payment being made as provided on the face of this Warrant. The undersigned certified check or bank draft and requests that certificates for such shares of Common Stock a certificate evidencing the Shares be issued as follows: Name: delivered to, _____________________________________, the address for whom is set forth below the signature of the undersigned: Dated: -------------------- ---------------------------------------------- (Signature) ---------------------------------------------- ---------------------------------------------- (Address) * * * ASSIGNMENT FORM To be signed only upon authorized transfer of Warrant. FOR VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers unto_____________________________________ Address: ___________________________________________________the right to purchase shares of Common Stock of Cafe Odyssey, Inc. to which the within Warrant relates and appoints____________________ _______________________________________________________________attorney, to transfer said right on the books of_________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number with full power of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered substitution in the name of, and delivered to, the undersigned at the address stated abovepremises. Dated: ______________________-------------------- ---------------------------------------------- (Signature) ---------------------------------------------- ---------------------------------------------- (Address)

Appears in 1 contract

Samples: Agreement Among Guarantors (Cafe Odyssey Inc)

SUBSCRIPTION FORM. To be Executed Date: ----------------- iVillage Inc. 000-000 0xx Xxxxxx Xxx Xxxx, XX 00000 Attn: President Ladies and Gentlemen: The undersigned hereby elects: / / to exercise the warrant issued to it by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, iVillage Inc. (the "Company") The undersigned and dated ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock 2001 (the "Common StockWarrant") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: ______________________________________________purchase ____________________________ Address: _____________________________________________________________shares of the Common Stock of the Company (the "Shares") purchasable thereunder at a purchase price of $0.01 per Share or an aggregate purchase price of $__________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all (the shares of Common Stock purchasable hereunder, that a new Warrant for "Purchase Price"). Pursuant to the balance remaining terms of the shares of Common Stock purchasable under Warrant the undersigned has delivered the Purchase Price herewith in full in cash or by certified check or wire transfer; or / / to surrender the right to purchase Shares pursuant to this Warrant and to receive in lieu thereof Shares pursuant to the provisions of Section 4 of the Warrant. The undersigned also makes the representations set forth on Attachment B attached to the Warrant. The certificate(s) for such shares shall be registered issued in the name of, and delivered to, of the undersigned at the address stated above. Datedor as otherwise indicated below: ______________________Very truly yours, -------------------------------------------------- (name of holder) By: ------------------------------------------- Name: ------------------------------------------- Title: -------------------------------------------

Appears in 1 contract

Samples: Securities Purchase Agreement (Ivillage Inc)

SUBSCRIPTION FORM. To be Be Executed by the Registered Holder of this Warrant if such Holder Desires in Order to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ________________Registered Holder hereby irrevocably elects to exercise ___________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase Warrants represented by this Warrant forcertificate, and to purchase thereunderthe securities issuable upon the exercise of such Warrants, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock securities shall be issued as follows: Name: __________________________________________________________________________ Address: _________________in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER ______________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ______________________________________________________ [please print or type name and address] and be delivered to ______________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________________________________________ ______________________________________________________ ______________________________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. _________________________________________ (Name of NASD Member) Dated: X ___________________________________ ___________________________________ ___________________________________ Address ___________________________________ Taxpayer Identification Number ___________________________________ Signature Guaranteed

Appears in 1 contract

Samples: Bion Environmental Technologies Inc

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SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in PartTO BE EXECUTED BY THE WARRANTHOLDER IF HE DESIRES TO EXERCISE THE WARRANT IN WHOLE OR IN PART: To: South Uintah Gas PropertiesSound Advice, Inc. (the "Company") The undersigned undersigned, ___________________________ (Social Security number _____________or taxpayer identification number ___, (Name of Subscriber: Warrantholder) (_________________________________________) (Please insert Social Security or other identifying number of Warrantholder) hereby irrevocably elects to exercise the right of purchase represented by this the within Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company Sound Advice, Inc. in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: ______________:____________________________________________________________ Address: _______________________________________________________________________ _______________________:_________________________________________________________ Deliver to: ______________:______________________________________________________ Address: _______________________________________________________________________ _______________________:_________________________________________________________ and, if such said number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this the within Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Datedbelow: Address:_________________________________________________________ Date:_________________________

Appears in 1 contract

Samples: Sound Advice Inc

SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: Part To: South Uintah Gas PropertiesGranite Financial, Inc. (the "Company") The undersigned ___________________________ (Social Security number ______________ Please insert Social Security or taxpayer identification other identifying number of Subscriber: _________________________) _____ hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ______________________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $___________________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ Deliver toto : ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: Signature _____________________________________________ Note: The signature on this Subscription Form must correspond with the name as written upon the face of this Warrant in every particular, without alteration or enlargement or any change whatever.

Appears in 1 contract

Samples: Granite Financial Inc

SUBSCRIPTION FORM. (To be Executed executed by the Holder of this Warrant if such Holder Desires registered holders to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Propertiesexercise the rights to purchase Common Shares evidenced by the within Warrant.) Power2Ship, Inc. (000 Xxxxx Xxxxx Road Boca Raton, Florida 33487 The undersigned, being the "Company") The undersigned ____________registered holder of the Warrant issued by Power2Ship, Inc. for the purchase of _______________ (Social Security number Common Shares issued ____________, 2006 accompanying this letter, hereby irrevocably exercises such Warrant for __________ Common Shares and herewith makes payment therefore by (check one): ____ check accompanying this Subscription Form or taxpayer identification _____ cashless exercise in accordance with the Warrant, and requests that a certificate for such Common Shares be issued in the name of the undersigned and be delivered to the undersigned at the address stated below. If such number of SubscriberCommon Shares shall not be all of the Common Shares issuable upon exercise of the attached Warrant, then a new Warrant shall be issued in the name of the undersigned for the balance remaining of such Common Shares less any fraction of a Common Share paid in cash. Dated: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: Print Name of Investor ____________________________________ Print Name of Joint Investor (if applicable) ____________________________________ Signature of Investor ____________________________________ Signature of Joint Investor (if applicable) Address:____________________________ ____________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________

Appears in 1 contract

Samples: Power2ship Inc

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