Common use of FORM OF ELECTION TO PURCHASE Clause in Contracts

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the 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:___________________________________________ 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:____________________________________________ 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)

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FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSTHOMXX XXXUP, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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 print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ number ------------------------------------------------------------------------------- (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 (Thomas Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if The signature to the registered holder desires foregoing Assignment and Certificate must correspond to exercise the name as written upon the face of this Rights represented by the Rights Certificate) Certificate in every particular, without alteration or enlargement or any change whatsoever. To: SIGNATURE INNS, INC. SUIZA FOODS CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One Preferred Common 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : ---------- Please print name and address: -------------------------------------- ---------------------------------------------------------------------- If such number of Rights shall are not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall will 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: -------------------------------------- ---------------------------------------------------------------------- The undersigned acknowledges that this Election to Purchase is voidable by the Company if it contains any material misstatement of fact by the undersigned. Dated:_________________________, [____]. _______________________________________ : ------------------------- ---------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Suiza Foods Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSTo CELL THERAPEUTICS, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:: _________________________ __________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ____________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ (Please print name and address) Dated:_______________: __________, [____]. _______________________________________ Signature Medallion Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Cell Therapeutics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSKITTY HAWK, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share shares of Series One A 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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 print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ number -------------------------------------------------------------------------------- (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 (Kitty Hawk Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder Holder desires to exercise Rights represented the Warrants evidenced by the Rights this Warrant Certificate) To: SIGNATURE INNS). TO CLEARVIEW CINEMA GROUP, INC. The undersigned hereby (1) irrevocably elects to exercise _exercise_______________ Rights Warrants represented by this Rights Warrant Certificate to purchase the number purchase__________ shares of hundredths of a share of Series One Preferred Common Stock issuable upon the exercise of the Rights such Warrants, (or such other securities 2) makes payment in full of the Company aggregate Exercise Price for such Warrants by enclosure of a bank cashier's check or money order therefor or by surrendering Warrants or shares of any other person which may Common Stock for application to the aggregate Exercise Price, upon condition that new Warrants be issuable upon issued for the exercise balance of the RightsWarrants remaining, and (3) and requests that certificates for such shares and Warrants be issued in the name of: (Please insert social security or other identifying number) ____________ -------------------------------------- (Please print name and address) If such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, a new Warrant Certificate for the balance remaining of such Warrants shall be registered in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number) ____________ -------------------------------------- (Please print name and address) DATED:_________________________________________, 19__ 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ ----------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Warrant Agreement (Clearview Cinema Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To AGOURON PHARMACEUTICALS, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number Common Shares (or such other securities of hundredths of a share of Series One 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 and delivered toof: ---------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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: ___________________________________________ 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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: SIGNATURE INNSGAMMA BIOLOGICALS, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate Certificates to purchase the number of hundredths shares of a share of Series One 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 the certificates for shares of Common Stock (or such shares other securities) constituting such Rights be issued in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : -------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ : -------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:______________________ ____, [____]. _____________________________________19__ ---------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Gamma Biologicals Inc

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNS, INC. Accuride Corporation The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all , as 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: _________________case may be): _____________________________________________________________ 55 (Please print name and address) _____________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number_______________________________________ ____________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: ____________________________ 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. MARKETSPAN CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 deliverable to: ----------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ) ----------------------------------------------------------- (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: ----------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ) ------------------------------------------------------------ (Please print name and address) ------------------------------------------------------------ ------------------------------------------------------------ Dated:_________________________, [____]. _______________________________________ ---------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 ------------------------------ 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. DOMINION BRIDGE CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ 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: , _______________________________________,_____ Dated:_________________________, [____]. _______________________________________ ----------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 CertificateCertificate pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To APPLIED MOLECULAR EVOLUTION, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths Common Stock (or such other securities of a share of Series One 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 and delivered toof: ---------------------------------------------------------------- (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 ) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- 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 print Complete only if Rights Certificate is to be registered in a name and addressother than the undersigned.) ------------------------------------------------------------------------ ------------------------------------------------------------------------ ---------------------------------------------------------------- Please insert social security or other identifying number:____________________________________________ number ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- Dated:_____________: ____________, [____]. _______________________________________ ------------------------------ ----------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSLOWE'S COMPANIES, INC. The .: Xxe undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share shares of Series One A 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:: ____________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:________________________: ____________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) _______________________________________________________________________________ (Please print name and address) Date: _______________, ____ ____________________________ Signature Signature Guaranteed: 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 THE RIGHT CERTIFICATE.) To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) ToGENZYME TRANSGENICS CORPORATION: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: Please insert social security or other identifying taxpayer 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 Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: -------------------- ----------------------------------------------------------------------- ----------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:Dated: _________, __ ____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSNational Vision Associates, INC. Ltd. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:_______________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _____________________________________________ (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:_____________________________________________ Dated:_____: ____________________, [____]. __________ ______________________________ Signature Signature Guaranteed: __________________________________________________________________Exhibit C ____________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:NATIONAL VISION ASSOCIATES, LTD. SHAREHOLDER RIGHTS PLAN Summary of Terms

Appears in 1 contract

Samples: Rights Agreement (National Vision Associates LTD)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSTNP ENTERPRISES, INC. The undersigned hereby irrevocably elects to exercise ________________ --------------- Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ------------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ : ------------------ --------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Texas New Mexico Power Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSMascoTech, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number --------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ --------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ --------------------------------------------------------------------------- Dated:_________: ________________, [____]. _____________ ___________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Mascotech Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights CertificateCertificate other than pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To APPLIED MOLECULAR EVOLUTION, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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 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 ) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- 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 print Complete only if Rights Certificate is to be registered in a name and addressother than the undersigned.) ------------------------------------------------------------------------ ------------------------------------------------------------------------ ---------------------------------------------------------------- Please insert social security or other identifying number:____________________________________________ number ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- Dated:_____________: ____________, [____]. _______________________________________ ---------------------------- ----------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. PERFORMANCE FOOD GROUP COMPANY The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the 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:___________________________________________ : -------------------- 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:____________________________________________ : -------------------- Dated:_________________________: , [____]. _______________________________________ ---------- ------ ----------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 -------------------------------------------------------------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Performance Food Group Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise the Rights represented by the this Rights Certificate) To: SIGNATURE INNSATMI, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________: ________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) __________________________________________________________________________ A new Rights Certificate evidencing the 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 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: ________________________ __________________________________________________________________________ (Please print name and address) __________________________________________________________________________ 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSXxXxxxxxx International, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 securities be issued in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number: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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ___________________(Please print name and address) ___________________________________________________________ 55 If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated: ________________, 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo SUMMIT PROPERTIES INC.: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: Please insert social security or other identifying taxpayer 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 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 print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying taxpayer number:____________________________________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ : --------------- ------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate ------------------------ 63 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. XXXXX CAPITAL CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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:___________________________________________ : ---------------------------- 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:____________________________________________ : ---------------------------- Dated:_________________________, [____]. _______________________________________ : --------------------------- ----------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 --------------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Lamar Capital Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSOMNIQUIP INTERNATIONAL, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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:___________________________________________ 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 -------------------------------------------------------------------------------- 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:__________________________________________________ -------------------------------------------------------------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Omniquip International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate) ToTo La Jolla Pharmaceutical Company: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ______________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that(Please print name and address) Dated: , Signature Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (La Jolla Pharmaceutical Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSTHOMXX XXXUP, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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 print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ number -------------------------------------------------------------------------------- (PLEASE PRINT NAME AND ADDRESS) -------------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ : -------------------------- -------------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 by the registered holder if such holder desires to exercise any or all of the Rights represented by the Rights this Right Certificate) To: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the 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:___________________________________________ If such ) 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 shall not be all pursuant to the Rights evidenced by this Rights Certificate, Agreement. The undersigned hereby requests that a new Rights Certificate certificate for the balance of any such Rights shall securities and any such property be registered issued in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ________________________________________________________________________________ 55 ________________________________________________________________________________ (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:________________________ (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 the registered holder desires to exercise the Rights represented by the this Rights Certificate) To: SIGNATURE INNSXxxxxx Xxxxxx VisionCare, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________: ________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) ______________________________________________________________________________ A new Rights Certificate evidencing the 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 mailed to (complete only if Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): Please insert social security or other identifying number: ________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Wesley Jessen Visioncare Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise any or all of the Rights represented by the this Rights Certificate.) To: SIGNATURE INNS, INC. SPRINT CORPORATION: The undersigned hereby irrevocably elects to exercise _________________________ (____)Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or taxpayer identification number ______________________________ ________________________________________________________________ (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:______________taxpayer identification number ______________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 (Sprint Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. LUMINEX CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ 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:_____________: ____________, [____]. _____________________________________200__ -------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 (Luminex Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. PG&E CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number Units 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 or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name of and delivered to: -------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- -------------------------------------------------------------------------- Please insert social security or other identifying number:_______________: ____________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: -------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ -------------------------------------------------------------------------- Please insert social security or other identifying number:________________: ____________________________ Dated:: ______________________ ____, [____]. ________________ ________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate CERTIFICATE ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Pacific Gas & Electric Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights CertificateRIGHTS CERTIFICATE) To: SIGNATURE INNSMED/WASTE, INC. The undersigned hereby irrevocably elects to exercise ________________ ---------------- Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One Preferred Stock issuable upon the exercise exer cise 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 be issued in the name of and delivered toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : -------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ : -------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ : ---------- ----------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this RIGHTS CERTIFICATE) Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Med Waste Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNSSERVICE MERCHANDISE COMPANY, INC. The undersigned hereby irrevocably elects to exercise ________________________ Rights represented by this Rights Certificate to purchase the number Units of hundredths of a share of Series One 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:___________________________________________ : --------------------- 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:____________________________________________ : --------------------- Dated:_________________________, [____]. _______________________________________ : ---------------------- -------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo ZOLL MEDICAL CORPORATION: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:: _______________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: _____________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_____________: ____________, [____]. _____ ___________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To AGOURON PHARMACEUTICALS, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number Common Shares (or such other securities of hundredths of a share of Series One 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 and delivered toof: ---------------------------------------------------------------- (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 ) ---------------------------------------------------------------- (Please print name and address) ---------------------------------------------------------------- The Rights Certificate for shall be returned to the balance undersigned (indicating the balance, if any, of such Rights shall 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ---------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate 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 (Agouron Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSTo NATIONAL TECHTEAM, INC. .: The undersigned hereby irrevocably elects to exercise _____________________ Rights represented by this Rights Right Certificate to purchase the number of one one-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 such Rights) and requests that certificates for such shares be issued in the name of and delivered toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) Should the number of Rights being exercised hereunder not be all the Rights evidenced by this Right Certificate, a new Right Certificate The undersigned hereby certifies by checking for the appropriate boxes thatbalance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ____________________ _______________________________________________________________________________ (Please print name and address) Dated:_____________________ Signature:__________________________________ (Signature must conform in all respects to the name of the holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (National Techteam Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. _________________________ The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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:____________________: _______________________ 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:____________________: ________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Dated: __________, _____ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

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

FORM OF ELECTION TO PURCHASE. (To be executed if The signature to the registered holder desires foregoing Assignment and Certificate must correspond to exercise the name as written upon the face of this Rights represented by the Rights Certificate) Certificate in every particular, without alteration or enlargement or any change whatsoever. To: SIGNATURE INNS, INC. SUIZA FOODS CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One Preferred Common 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : ------------- Please print name and address: ---------------------------------------- ----------------------------------------------------------------------- If such number of Rights shall are not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall will 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: ---------------------------------------- ----------------------------------------------------------------------- The undersigned acknowledges that this Election to Purchase is voidable by the Company if it contains any material misstatement of fact by the undersigned. Dated:_________________________, [____]. _______________________________________ : ------------------------ --------------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Suiza Foods Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Xxxx Xxxxxxx Financial Services, Inc.: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares of hundredths of a share of Series One 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:__________________, _______, _ [____]. _____________Form of Election to Purchase -- continued] __________________________ Signature (Signature Guaranteed: ______________________________________________________________________________ 55 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: SIGNATURE INNSAlloy, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares or portion thereof 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 insert social security or other identifying number ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature : -------------------------- Signature Guaranteed: ______________________________________________________________________________ 55 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: SIGNATURE INNS, INC. THE EARTHGRAINS COMPANY: The undersigned hereby irrevocably elects to exercise ________________ ---------- Rights represented by this Rights Certificate to purchase the number shares 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:___________________________________________ 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: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. _________________________ The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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:______________________: _____________________ 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:_______________________: _____________________ Dated:____________, _____________, [____]. ___________ _____________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Arbitron Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder Holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNSWarrant. TO LOGICAL DESIGN SOLUTIONS, INC. .: The undersigned hereby irrevocably elects to exercise ____the Warrant evidenced by this Warrant Certificate No. ____________ Rights represented by this Rights Certificate to purchase the 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:___________________________________________ If such number Shares of Rights shall not be all Common Stock issuable upon the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance exercise of such Rights shall Warrant and requests that certificates for such Shares be registered issued in the name of and delivered toof: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number-------------------------------------- Name -------------------------------------- Address -------------------------------------- Social Security Number -------------------------------------- Date:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature (Signature Guaranteedmust conform in all respects to name of holder as specified on the face of this Warrant Certificate) If such number of Shares shall not be all the Shares with respect to which this Warrant is exercisable, a new Warrant for the balance remaining of such Shares will be registered in the name of and delivered to: __________________________________________________________-------------------------------------- Name -------------------------------------- Address -------------------------------------- Social Security Number -------------------------------------- Date:____________________ 55 Certificate The undersigned hereby certifies by checking Signature (Signature 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: Warrant Agreement (Logical Design Solutions Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSAmerican Securities Transfer & Trust, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number -------------------------------------------------- --------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ --------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------- --------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ --------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ : ----------------------------- ---------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate) To: SIGNATURE INNSTo North American Scientific, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One Preferred Stock Common Shares 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 securities be issued in the name of and delivered toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: _____________________________________________________________________________ (Please print name and address) _____________________________________________________________________________ 55 If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate The 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) _____________________________________________________________________________ Optional Election to Exercise without Payment of Cash: With respect to the exercise of ____________ of the Rights specified above, the undersigned hereby certifies by checking elects to exercise such Rights without payment of cash and to receive a number of Common Shares or other securities having a value (as determined pursuant to the appropriate boxes thatRights Agreement) equal to the difference between (i) the value of the Common Shares or other securities that would have been issuable upon the exercise thereof upon payment of the cash amount as provided in the Rights Agreement, and (ii) the amount of such cash payment. Dated: , ____ ___________________________________ Signature Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (North American Scientific Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSDesktop Metal, INC. Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:, as the case may be): ___________________________________________ 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: _________________(Please print name and address) _____________________________________________________________ 55 If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number_____________________________________ ____________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: 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 (Desktop Metal, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSTo WARRXX XXXCORP, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:______________________: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying taxpayer number:_______________________: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:______________: ___________, [____]. _____ ___________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. CONSOLIDATED STORES CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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: ________________ __, _____ ___________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:Signature

Appears in 1 contract

Samples: Rights Agreement (Consolidated Stores Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. PULASKI FURNITURE CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number: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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ (Please print name and address) Date: _______________, ____ _____________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:: (1) the Rights evidenced by this Rights Certificate [ ] are [ ] are not being exercised by or on behalf of a Person who is or was an Acquiring Person or an Affiliate or Associate of any such Acquiring Person (as such terms are defined pursuant to the Rights Agreement);

Appears in 1 contract

Samples: Rights Agreement (Pulaski Furniture Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. [____________] The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number Units of hundredths of a share of Series One 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 Preferred Stock be issued in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteedof: ______________________________________________ (Name) ______________________________________________ 55 (Address) ______________________________________________ (Social security or other identifying number) A new Rights Certificate The evidencing the remaining balance, if any, of such Rights not hereby exercised shall be mailed to and registered in the name of the undersigned hereby certifies unless such person requests that such Rights Certificate be registered in the name of and mailed to (complete only if a Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): ______________________________________________ (Name) ______________________________________________ (Address) ______________________________________________ (Social security or other identifying number) DATED: ______________, 20__ _____________________________ Signature Signature Guaranteed: Signatures must be guaranteed by checking an eligible guarantor institution with membership in a recognized signature guarantee medallion program as approved by the appropriate boxes that:Stock Transfer Association.

Appears in 1 contract

Samples: Rights Agreement (Think Partnership Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSAlloy, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares or portion thereof 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 insert social security or other identifying number ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature : --------------------------- Signature Guaranteed: ______________________________________________________________________________ 55 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: SIGNATURE INNS, INC. CORAM HEALTHCARE CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share shares of Series One 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ----------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ -------------- ------- ---------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented evidenced by the Rights Right Certificate.) To: SIGNATURE INNS, INC. AMLI RESIDENTIAL PROPERTIES TRUST The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___: ________________________________________ -------------------------------------------------- (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Rights 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:____: ________________________________________ Dated:-------------------------------------------------- (Please print name and address) Date: _____________________ _____, [19____]. __________ ______________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Amli Residential Properties Trust)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSINTELLIGENT ELECTRONICS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number Units 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 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) ______________________________ Please insert social security or other identifying number: __________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be he registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:(Please print name and address) _________________________, [____]. _ Please insert social security or other identifying number: _________________ Dated: ______ __, 199_/200_ ______________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Intelligent Electronics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise :___________________ The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ 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: _____________ Dated:_________________________, [____]. _______________________________________ ------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (National Patent Development Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Marathon Rights represented by the Marathon Rights Certificate) To: SIGNATURE INNS, INC. USX CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Marathon Rights represented by this Marathon Rights Certificate to purchase the number shares of hundredths of a share of Series One 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ --------------------------------------------------------------------------- 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ --------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ ------------ ----- --------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. [Company Name] The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share of Series One 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: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, XXXXX & COMPANY INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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:number ________________________ (Please print name and address): _________________________ _________________________ _________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:number (Please print name and address): _________________________ _________________________ _________________________ Dated:: _________________________, [____]. ______________________ Signature: __________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Section 382 Rights Agreement (COHEN & Co INC.)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo Principal Financial Group, Inc.: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares of hundredths of a share of Series One Preferred Stock issuable upon the exercise of the such Rights (or such other securities of the Company Corporation or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered toof: Please insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:57 [Form of Election to Purchase -- continued] -------------------------- Signature

Appears in 1 contract

Samples: Rights Agreement (Principal Financial Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNSFREEMARKETS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share Units of Series One 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:___________________________________________ : ------------------------ 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:____________________________________________ : ------------------------ Dated:_________________________, [____]. _______________________________________ : ------------------- ---------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSTo ANIKA THERAPEUTICS, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: Please insert social security or other identifying taxpayer 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 Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: --------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ ------------------ --- ----------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:-----------------------

Appears in 1 contract

Samples: Shareholder Rights Agreement (Anika Therapeutics Inc)

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FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. SOUTHTRUST CORPORATION: The undersigned hereby irrevocably elects to exercise ________________________ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other Identifying number -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________: , [____]20 . _______________________________________ ------------------- ---- --- ------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, ARMCO INC. The undersigned hereby irrevocably elects to exercise ________________ --------------- Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number ----------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ----------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ----------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ----------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ ---------------- ----- -------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 - 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. CERIDIAN CORPORATION: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ____________________________________________________________________________,__ 55 ----------------------------------- Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Ceridian Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSTo BELLAVISTA CAPITAL, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares of hundredths of a share of Series One 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:_______________________________: ____________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying taxpayer number:________________________________: ____________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (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: Shareholder Rights Agreement (Bellavista Capital Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if by the registered holder if such holder desires to exercise the Rights represented evidenced by the this Rights Certificate) To: SIGNATURE INNS, INC. MIM CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Rights Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : --------------------------------------------------- -------------------------------------------------------------------------------- (Please print name) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print address) If such number of Rights shall not be all of the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ : --------------------------------------------------- -------------------------------------------------------------------------------- (Please print name) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (Please print address) Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 by the registered holder if such holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSSIS BANCORP, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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 print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:_________________________number ___________________ ----------------------------------------------------------------------------- (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 (Sis Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, AMERICAN PRECISION INDUSTRIES INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (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 (American Precision Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. DOLLAR GENERAL CORPORATION The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Certificate to purchase the number Units of hundredths of a share of Series One 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:___________________________________________ 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:____________________________________________ Dated:: _________________________, [____]. ________________ ________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Dollar General Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSUNITED DOMINION REALTY TRUST, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths of a share shares of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ 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:__________Date: _______________, [____]. _______________________________________ -------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTo COURIER CORPORATION: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares 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 toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying taxpayer number:_________________________: __________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights Certificateare being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Rights Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: --------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ ------------------- ---- ------------------------------------ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise the Rights represented by the this Rights Certificate) To: SIGNATURE INNSDAVEL COMMUNICATIONS, INC. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________: ________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address) ______________________________________________________________________________ A new Rights Certificate evidencing the 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 mailed to (complete only if Rights Certificate evidencing any remaining balance of Rights is to be registered in a name other than the undersigned): Please insert social security or other identifying number: ________________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Davel Communications Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSMarvel Enterprises, INC. Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ------------------------------------------------------------- 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ------------------------------------------------------------ Dated:_________________________, [____]. _______________________________________ : -------------------- ---------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNS, INC. QUAKER FABRIC CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number shares of hundredths of a share of Series One 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 (Please print name and address of transferee) If such number of Rights specified above shall not be all the Rights evidenced by this Right Certificate, the Rights Agent shall place an appropriate notation on this Right Certificate with respect to those Rights exercised or 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) _________________________________________________________________ (Please print name and address of transferee) Dated: ______________, 19__ ________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

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

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSINSIGHT ENTERPRISES, INC. : The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 deliverable to: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ 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: ______________________________________________________________________________ 55 ------------------------------ Signatures must be guaranteed by a member firm of a registered national stock 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. 47 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Insight Enterprises Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSORCHID BIOSCIENCES, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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: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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 ________________________________________________________________________________ (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 Guaranteed: Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Orchid Biosciences Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSDT INDUSTRIES, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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: ---------------------------------------------- ----------------------------------------------------------------------------- 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 ------------------ Please print name and address: ---------------------------------------------- ----------------------------------------------------------------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Dt Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNSCELLULAR COMMUNICATIONS OF PUERTO RICO, INC. .: The undersigned hereby irrevocably elects to exercise ________________ --------------------- Rights represented by this Rights Certificate to purchase the number shares 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 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: ______________________________________________________________________________ 55 Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Corecomm Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNSKaltura, INC. Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:, as the case may be): ___________________________________________ 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:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: _________________(Please print name and address) _____________________________________________________________ 55 If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number_____________________________________ ____________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: __________________ 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. US-DOCS\133785809.2 The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Kaltura Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO : SIGNATURE INNS, INC. --------------------- The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Right Certificate to purchase the number shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : ------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ : ------------------------------------------------- ------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------------- Dated:_________________________: -------------, [____]. _______________________________________ ---- --------------------------------------------- Signature (Signature Guaranteed: ______________________________________________________________________________ 55 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) EXHIBIT C TO RIGHTS AGREEMENT TERMS OF THE SERIES A JUNIOR PREFERRED STOCK

Appears in 1 contract

Samples: Rights Agreement (Usw-C Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INCCHICAGO RIVET & MACHINE CO. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares ----------- 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 print social security or other identifying number:___________________________________________ ) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: -------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ -------------------------------------------------------------- (Please insert print social security or other identifying number:____________________________________________ ) Dated:_________________________: 19 ---------------, [____]. _______________________________________ -- ----------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 ----------------------- Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Chicago Rivet & Machine Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) ToTO NEW PLAN REALTY TRUST: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ______________________ Rights represented by this Rights Right Certificate to purchase the number Shares of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ : ------------------------------ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ : ---------------------- -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- Dated:__________: _______________, [____]. _____________________________________19__ ------------------------------------ Signature (Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. First Chicago Trust Company of New York The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number ---------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ---------------------------------------------------- -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ -------------- ---- ------------------------------ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Dated:_________: ________________, [____]. _______________________________________ --------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights CertificateCertificate other than pursuant to Section 11(a)(ii) of the Rights Agreement.) To: SIGNATURE INNSVINA TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number of hundredths one one-thousandths 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 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ) -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- If such number of Rights shall not be all 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- Dated:_____________: ____________, [20____]. _______________________________________ ---------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 signature to the registered holder desires foregoing Assignment and Certificate must correspond to exercise the name as written upon the face of this Rights represented by the Rights Certificate) Certificate in every particular, without alteration or enlargement or any change whatsoever. To: SIGNATURE INNSPRECEPT BUSINESS SERVICES, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One Preferred Class A Common 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number: ______________ Please print name and address:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: _____________________________________________________________________________. If such number of Rights are not all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will be registered in the name of and delivered to: * Please insert social security or other identifying number: ______________ 55 Please print name and address:___________________________________________ _____________________________________________________________________________. Dated: ______________ Signature 41 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Precept Business Services Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNS, INC. HILTON HOTELS CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One 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 print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ ------------------------------------------------------------ If such number of Rights shall not be all the Rights evidenced by this Rights Right Certificate, a new Rights Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ------------------------------------------------------------ (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ ------------------------------------------------------------ Dated:_________________________, [____]. _______________________________________ : ------------------------ ------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate --------------------- 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 (Hilton Hotels Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNS, HOLLINGER INTERNATIONAL INC. The undersigned hereby irrevocably elects irrevoxxxxx xxxcts to exercise ________________ Rights represented by this Rights Right Certificate to purchase the number of hundredths of a share of Series One Preferred Stock Z Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Company or of any other person which entity that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered toof: (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:: ___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ______(Please print name and address) ________________________________________________________________________ 55 If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: _______________________________________________ (Please print name and address) ________________________________________________________________________ Dated: __________________, 20__ _________________________ Signature Signature Guaranteed: CERTIFICATE ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Hollinger International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. CADMUS COMMUNICATIONS CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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:__________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 (Cadmus Communications Corp/New)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. FORWARD AIR CORPORATION The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Rights Certificate to purchase the number Units of hundredths of a share of Series One 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:______________________: _____________________ 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:_______________________: _____________________ Dated:_________________________, [____]. _______________________________________ : ---------------------------- ---------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 -------------------------------------------------------------------------------- 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. ---------------------------- The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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:___________________________________________ : ----------------------------- 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:____________________________________________ : ----------------------------- --------------------------------- Dated:_________________________: , [____]. _______________________________________ ------------ ---- ------ ----------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Smith Charles E Residential Realty Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate) To: SIGNATURE INNS, INC. DYERSBURG CORPORATION The undersigned hereby irrevocably elects to exercise ________________________ Rights represented by this Rights Certificate to purchase the number Units of hundredths of a share of Series One 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:___________________________________________ : --------------------- 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:____________________________________________ : --------------------- Dated:_________________________, [____]. _______________________________________ : -------------------------- --------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 -------------------------------------------------------------------------------- 46 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Dyersburg Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. HYPERION SOFTWARE CORPORATION: The undersigned hereby irrevocably elects to exercise _________exercise_______ Rights represented by this Rights Certificate to purchase the number shares 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 insert social security or other identifying number -------------------------------------------------------------------------- (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number -------------------------------------------------------------------------- -------------------------------------------------------------------------- (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ : --------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Certificate.) ToTO: SIGNATURE INNS, INCST. JOSEPH LIGHT & POWER COMPANY The undersigned hereby irrevocably elects irrevocxxxx xlects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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 (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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security or other identifying number:___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated:_________________________, [____]. _______________________________________ Signature Signature Guaranteed: ___________________number ___________________________________________________________ 55 (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 (St Joseph Light & Power Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To GPU, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths Common Stock (or such other securities of a share of Series One 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 and delivered toof: 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 -------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ 19 -------------------- ---- ------------------------------------ Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights CertificateCertificate pursuant to Section 11(a)(ii) of the Rights Agreement.) To: SIGNATURE INNSVINA TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths Common Stock (or such other securities of a share of Series One 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 and delivered toof: -------------------------------------------------------------------------------- (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 ) -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- Dated:_____________: ____________, [20____]. _______________________________________ ---------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 CertificateCertificate other than pursuant to Section 11(a)(ii) To: SIGNATURE INNSof the Rights Agreement.) To GPU, INC. .: The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- 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 -------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ -------------------------------------------------------------------------------- Dated:_________________________: , [____]. _______________________________________ 19 -------------------- -- ------------------------------------------- Signature Signature Guaranteed: ______________________________________________________________________________ 55 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 the registered holder desires to exercise Rights represented by the Rights Right Certificate.) To: SIGNATURE INNS, INC. RIGHTS AGENT The undersigned hereby irrevocably elects to exercise _________exercise_______ Rights represented by this Rights Certificate to purchase acquire in exchange for the number surrender of hundredths such Rights the shares of a share of Series One Preferred Common 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 (or other securities) be issued in the name of and delivered to: ------------------------------------------------------------------------------ (Please print name and address) ----------------------------------------------------------------------- ----------------------------------------------------------------------- Please insert social security ------------------------------------------------------------------------------ Social Security or other identifying number:___________________________________________ Other Tax Payer Identification 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 ------------------------------------------------------------------------------ Social Security or other identifying number:____________________________________________ Other Tax Payer Identification Number: --------------------- Dated:_________________________: , [____]------------------ --- ------ ---------------------------------- Signature SIGNATURE GUARANTEED: Signatures must be guaranteed by an eligible guarantor institution (a bank, stockbroker, savings and loan association or credit union with membership in an approved guarantee medallion program) pursuant to Rule 17Ad-15 of the Securities Exchange Act of 1934. _______________________________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 ------------------------------------------ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (JLG Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. UNIROYAL TECHNOLOGY CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares 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) Please insert social security or other identifying number:________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) ------------------------------------------------------------------------ ------------------------------------------------------------------------ Please insert social security or other identifying number:____________________________________________ Dated(Please print name and address) Please insert social security or other identifying number:_________________________, [____]. _ Dated: ____________________ ____________________ Signature Signature Guaranteed: ______________________________________________________________________________ 55 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Uniroyal Technology Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: SIGNATURE INNS, INC. Mansxx Xxxustries Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Rights Certificate to purchase the number shares of hundredths of a share of Series One 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) ----------------------------------------------------------------------- ----------------------------------------------------------------------- -------------------------------------------------------------------------------- (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: ______________________________________________________________________________ 55 Certificate 41 CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Mansur Industries Inc)

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