Common use of FORM OF ELECTION TO PURCHASE Clause in Contracts

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ ___________________________________________________________ (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.

Appears in 2 contracts

Samples: Rights Agreement (Pericom Semiconductor Corp), Rights Agreement (Pericom Semiconductor Corp)

AutoNDA by SimpleDocs

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Rights represented by this Rights Certificate.) To: Pericom Semiconductor Corporation Valassis Communications, Inc. The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ Rights represented by this Rights Certificate to purchase the shares of preferred stock or other securities, cash or other property issuable upon the exercise of the Rights and requests that certificates for the shares or other securities be issued in the name of, and the cash or other property be paid to: Please insert social security or other identifying number --------------------------------------------------------- (Please print name and address) ___________________________________________________________ --------------------------------------------------------- If such the number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the remaining balance remaining of such the Rights shall be registered in the name of and delivered to: Please insert social security or other identifying numbernumber --------------------------------------------------------- (Please print name and address) --------------------------------------------------------- Dated: ________________,____ ___________________________________________________________ Signature --------------------------- (Please print Signature must conform in all respects to name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” of holder as defined in Rule 17Ad-15 promulgated under specified on the Securities Exchange Act face of 1934, as amended.this Rights Certificate)

Appears in 2 contracts

Samples: Rights Agreement (Valassis Communications Inc), Rights Agreement (Valassis Communications Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.Warrants) ToTO: Pericom Semiconductor Corporation VION PHARMACEUTICALS, INC. The undersigned hereby irrevocably elects to exercise Rights Warrants represented by this Right Warrant Certificate to purchase the Preferred Shares __________ shares of Common Stock issuable upon the exercise of such Rights (or such other securities or property of the Company or of any other Person which may be issuable upon the exercise of the Rights) Warrants and requests that certificates for such shares of Common Stock be issued in the name of: ____________________________________ Please insert social security, tax identification or other identifying number ___________________________ ___________________________ ___________________________ If such number of Warrants is not 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 insert social security, tax identification or other identifying number ___________________________ ___________________________ ___________________________ (Please print name and address) Dated:___________________________________________________________ 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: ____________________ ___________________________________________________________ Signature (Please print Signature must conform in all respects to name and addressof holder as specified on the face of the Warrant Certificate) ___________________________________________________________ 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.:

Appears in 2 contracts

Samples: Warrant Agreement (Vion Pharmaceuticals Inc), Warrant Agreement (Vion Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation Swift Energy Company The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series A Junior Participating Preferred Shares Stock issuable upon the exercise of such the Rights (or such other securities or property of the Company or of any other Person which person 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 Junior Participating Preferred Stock (or such other securities of the Company or of any other person or such other property as may be issuable upon the exercise of the Rights) be issued in the name ofof 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) ___________________________________________________________ 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: :________________________ Dated:___________________ ___________________________________________________________ (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.:

Appears in 2 contracts

Samples: Rights Agreement (Swift Energy Co), Rights Agreement (Swift Energy Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo Reinsurance Group of America, Incorporated: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: _______________________________________Name:____________________ (Please print name and address) Address:__________________ __________________________________________ Social security or taxpayer identification number:__________________ 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 Name:____________________ Address:__________________ ___________________ Social security or other identifying taxpayer identification number: :__________________ Dated:__________________ ___________________________________________________________ Signature (Please print Signature must conform in all respects to name and addressof holder as specified on the face of this Right Certificate) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a member or a participant in Rule 17Ad-15 promulgated under the Securities Transfer Agent Medallion Program, the New York Stock Exchange Act of 1934, as amendedMedallion Signature Program or the Stock Exchange Medallion Program.

Appears in 2 contracts

Samples: Section 382 Rights Agreement (Reinsurance Group of America Inc), Section 382 Rights Agreement (Reinsurance Group of America Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo TEKELEC: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ____________________________ Rights represented by this Right Certificate to purchase the shares of Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:________________________________ (Please print name and address) Address:_____________________________ ___________________________ Social security or taxpayer identification number:_______________ 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: Name:________________________________ Address:_____________________________ ___________________________ Social security or taxpayer identification number:_______________ Dated:_____________________________, ____ (Please print name and address) ___________________________________________________________ Dated: Signature (Signature Medallion must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a member or a participant in Rule 17Ad-15 promulgated under the Securities Transfer Agent Medallion Program, the New York Stock Exchange Act of 1934, as amendedMedallion Signature Program or the Stock Exchange Medallion Program.

Appears in 2 contracts

Samples: Rights Agreement (Tekelec), Rights Agreement (Tekelec)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) ToTO: Pericom Semiconductor Corporation FXCM INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such Rights (or such other securities 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 share(s) be issued in the name offollowing name: Please insert social security or other identifying number:______________________________________________________________ ________________________________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this 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: ______________________________________________ Dated: ___________ ___, _____ ______________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by a participant in a Medallion Signature Guarantee Program at a guarantee level acceptable to the Corporation’s Rights Agent. The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not, and never have been, beneficially owned by an “eligible guarantor institution” Acquiring Person or an Affiliate or Associate thereof (as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended.Rights Agreement). ______________________________ Signature

Appears in 2 contracts

Samples: Rights Agreement (FXCM Inc.), Rights Agreement (FXCM Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) ToTO: Pericom Semiconductor Corporation DOVER DOWNS GAMING & ENTERTAINMENT, INC. The undersigned hereby irrevocably elects to exercise ______________________________________ Rights represented by this Right Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of such Rights (or such other securities 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 share(s) be issued in the name ofname: ___________________________________________________________ (Please print name and address) ___________________________________________________________ Please insert social security or other tax identifying number 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) __________________Please insert social security or other tax identifying number _________________________________________ Dated: Signature Signature Medallion Guaranteed: ______________ ____, 20_______ ______________________ Signature (Signature must conform in all respects to name/s of holder/s as specified on the face of this Right Certificate) Signature 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.. The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Dover Downs Gaming & Entertainment Inc), Rights Agreement (Dover Downs Gaming & Entertainment Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation Southwest Water Company The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ____________________________________________________________ (Please print name and address) ____________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ___________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: Signature Signature Medallion Guaranteed: __________________ _________________________ Signature Signature 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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Southwest Water Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation Hyseq, Inc. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: Please insert social security or other identifying number _________________________________________ (Please print name and address) _________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance 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) ____________________________________________________________ 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 toDated: 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.

Appears in 1 contract

Samples: Rights Agreement (Hyseq Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Rights Certificate.) To: Pericom Semiconductor Corporation To IDEC PHARMACEUTICALS CORPORATION The undersigned hereby irrevocably elects to exercise ___________________________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: _________Please insert social security or other identifying number__________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ ___________________________________________________________ (Please print name and address) Dated: __________________, ______________ ____________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by a participant in a Securities Transfer Association Inc. recognized signature guarantee medallion program. B-5. 54 Form of Reverse Side of Rights Certificate -- continued -------------------------------------------------------------------------------- CERTIFICATION The undersigned hereby certifies that the Rights evidenced by this Rights Certificate are not beneficially owned by an “eligible guarantor institution” Acquiring Person or an Affiliate or Associate thereof (as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedRights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Idec Pharmaceuticals Corp / De)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation Sinovac Biotech Ltd. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Series C Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 (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: of (or to, as the case may be): ___________________________________________________________ (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 U.S. social security or other identifying number: ____________________ ___________________________________________________________ (Please print name and address) _________________________________________Dated: __________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under the U.S. Securities Exchange Act of 1934, as amended., which is a member of a recognized Medallion Signature Guarantee Program. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Sinovac Biotech LTD)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo Shorewood Packaging Corporation: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ (Please print Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name and address) of: Name: _________________________ Address: ______________________ ______________________ Social security or taxpayer identification number: _______________________ 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 numberName: _________________________ Address: ______________________ ______________________ Social security or taxpayer identification number: _______________________ Dated: ___________, 19__ ___________________________________ Signature (Please print Signature must conform in all respects to name and addressof holder as specified on the face of this Right Certificate) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an "eligible guarantor institution" meeting the requirements of the Rights Agent, which requirements include membership or participation in STAMP or such other "signature guarantee program" as defined may be determined by the Rights Agent in Rule 17Ad-15 promulgated under addition to, or in substitution for, STAMP, ass in accordance with the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Shorewood Packaging Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation FURNITURE BRANDS INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series B Preferred Shares Stock issuable upon the exercise of such the Rights (or such other securities or property of the Company or of any other Person which person or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series B Preferred Stock (or such other securities of the Company or of any other person or such other property as may be issuable upon the exercise of the Rights) be issued in the name ofof 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) ___________________________________________________________ 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: :________________________ Dated:___________________ ___________________________________________________________ (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.:

Appears in 1 contract

Samples: Rights Agreement (Furniture Brands International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation Dex Media, Inc. The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: _________________________________________________________________________ (Please print name and address) _________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Dated: Signature Signature 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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Dex Media Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation The New Home Company Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Series A Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 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: of (or to, as the case may be): ___________________________________________________________ (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 that:

Appears in 1 contract

Samples: Tax Benefit Preservation Plan (New Home Co Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation Frontier Airlines, Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of such the Rights (or such other securities or property of the Company or of any other Person which person that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name ofof and delivered to: ___________________________________________________________ (Please print 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 address) ____________________________delivered to: _______________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number _______________________________ _______________________________ _______________________________ (Please print name and address) Dated:__________ __, ____________________ _______________________________ 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.Signature

Appears in 1 contract

Samples: Rights Agreement (Frontier Airlines Inc /Co/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Rights Certificate.) To: Pericom Semiconductor Corporation To PHARMACYCLICS, INC. The undersigned hereby irrevocably elects to exercise ___________________________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: _______Please insert social security or other identifying number ____________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ _______number ____________________________________________________ (Please print name and address) Dated: __________________, 19__ ________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by a participant in a Securities Transfer Association Inc. recognized signature guarantee medallion program. B-5. 50 Form of Reverse Side of Rights Certificate -- continued -------------------------------------------------------------------------------- CERTIFICATION The undersigned hereby certifies that the Rights evidenced by this Rights Certificate are not beneficially owned by an “eligible guarantor institution” Acquiring Person or an Affiliate or Associate thereof (as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedRights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Pharmacyclics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation SOFTECH, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares shares of Common Stock (or other securities or property) issuable upon the exercise of such Rights (or such other securities 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 of Common Stock (or such other securities) be issued in the name of: _________________________________________________________________________ (Please print name and address) _________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ___________________________________________________________ (Please print name and address) _________________________________________________________________________ Dated: Signature Signature Medallion Guaranteed: :________________________ ________________________________________ Signatures Signature (Signature must conform to holder specified on Right Certificate) Signature Guaranteed: Signature must be guaranteed by a bank, trust company, broker, dealer or other eligible institution participating in a recognized signature guarantee medallion program. Form of Reverse Side of Right Certificate - continued _________________________________________________________________________ (To be completed) The undersigned certifies that the Rights evidenced by this Right Certificate are not beneficially owned by, and were not acquired by the undersigned from, an “eligible guarantor institution” Acquiring Person or an Affiliate or Associate thereof (as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended.Rights Agreement). __________________________________________ Signature

Appears in 1 contract

Samples: Rights Agreement (Softech Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTO PHOTRONICS, INC.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: ____________________________________________________________________________ (Please insert Social Security or other identifying number:_________________________________________________________. Please print name and address) : ___________________________________________________________ __________.) If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ ____________________________________. (Please insert Social Security or other identifying number:_________________________________________________________. Please print name and address: ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated.) Date: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an eligible guarantor institution” as defined institution (bank, stock broker or savings and loan association with membership in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended.an approved signature medallion program). Date:

Appears in 1 contract

Samples: Section 382 Rights Agreement (Photronics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right CertificateRights Certificate other than pursuant to Section 11(a)(ii) of the Rights Agreement.) ToTO: Pericom Semiconductor Corporation HOLLYSYS AUTOMATION TECHNOLOGIES LTD. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities or property 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: insert social security or other identifying number) ___________________________________________________________________________ (Please print name and address) If applicable, the Rights Certificate indicating the balance, if any, of such Rights which may still be exercised pursuant to Section 11(a)(ii) of the Rights Agreement shall be returned to the undersigned unless such Person requests that the Rights Certificate be registered in the name of and delivered to: Please insert social security or other identifying number (complete only if Rights Certificate is to be registered in a name other than the undersigned) (Please print name and address) Dated: _________________________, 20 . __________________________________ 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” Eligible Guarantor Institution, as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Hollysys Automation Technologies, Ltd.)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: Pericom Semiconductor Corporation Xxxxxx Bancorp, Inc. The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________ Rights represented by this Right Certificate to purchase Preferred 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 securities be issued in the name of and delivered to: Please insert social security or other identifying number _________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ __________________________________number _________________________ (Please print name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: _____________________________________, 201___ 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.Signature Medallion Signature Guaranteed:

Appears in 1 contract

Samples: Tax Benefits Preservation Plan (Porter Bancorp, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation AutoZone, Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ____________________________________________________________ (Please print name and address) ____________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ___________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signature Signature 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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement Rights Agreement (Autozone Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation CTPartners Executive Search Inc. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series A Preferred Shares Stock issuable upon the exercise of such the Rights (or such other securities or property of the Company or of any other Person which person 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 (or such other securities of the Company or of any other person or such other property as may be issuable upon the exercise of the Rights) be issued in the name ofof 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) ___________________________________________________________ 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: :________________________ Dated:___________________ ___________________________________________________________ (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.:

Appears in 1 contract

Samples: Rights Agreement (Ctpartners Executive Search Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if the holder desires to exercise the Right Certificate.) ToTo Nordson Corporation: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Certificate to purchase the Preferred Common Shares or other securities issuable upon the exercise of such Rights (or such other securities 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 therefor be issued in the name of: _____________________________________________________________________________ (Please print name and address) _____________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: _________________________________________________ If such number of Rights are not all of 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 print name and address) _____________________________________________________________________________ Dated: Signature Signature Medallion GuaranteedPlease insert social security or other identifying number: _________________________________________________ Signatures Dated:________________________ ________________________________________ Signature (Signature must be guaranteed conform in all respects to name of the holder as specified on the face of this Right Certificate) Signature Guaranteed: CERTIFICATE (Applicable to Form of Election to Purchase) The undersigned hereby certifies by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Nordson Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo Urstadt Bxxxxx Properties Inc.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise _________________________ Rights represented by this Right Certificate to purchase the Preferred Shares (or other securities) issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: Please insert social security or other identifying number: _____________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance 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: _____________________, __________ ___________________________________ Signature (Signatures to the foregoing Election to Purchase and the following certificate must be guaranteed by an “eligible guarantor institution” conform in all respects to name of holder as defined in Rule 17Ad-15 promulgated under specified on the Securities Exchange Act face of 1934, as amended.this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Urstadt Biddle Properties Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo ChaseMellon Shareholder Services L.L.C.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: Name: ___________________________________________________________ (Please print name and address) Address: _______________________________________________ Social Security or Taxpayer I.D. No.: ______________________________________________ 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 an delivered to: Please insert social security or other identifying numberName: ____________________ ___________________________________________________________ (Please print name and address) Address: _______________________________________________ Social Security or Taxpayer I.D. No.: ______________________________________________ Dated: Signature Signature Medallion Guaranteed: ___________, _____ __________________________________ Signatures Signature (Signature must be guaranteed by an “eligible guarantor institution” conform in all respects to name of holder as defined in Rule 17Ad-15 promulgated under specified on the Securities Exchange Act face of 1934, as amended.this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (Coeur D Alene Mines Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right CertificateRights Certificate pursuant to Section 11(a)(ii) of the Rights Agreement.) ToTO: Pericom Semiconductor Corporation HOLLYSYS AUTOMATION TECHNOLOGIES LTD. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the Preferred Ordinary Shares issuable upon the exercise of such Rights (or such other securities or property of the Company or of any other Person which may be Company) issuable upon the exercise of the Rights) Rights and requests that certificates for such shares be issued in the name of: ___________________________________________________________________________ (Please insert social security or other identifying number) ___________________________________________________________________________ (Please print name and address) ___________________________________________________________________________ If such number of The Rights shall not be all Certificate indicating the Rights evidenced by this Right Certificatebalance, a new Right Certificate for the balance remaining 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: number (complete only if Rights Certificate is to be registered in a name other than the undersigned) ____________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ , 20 . Signature Signature Medallion Guaranteed: Signatures must be guaranteed by an “eligible guarantor institution” Eligible Guarantor Institution, as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Hollysys Automation Technologies, Ltd.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation ARV ASSISTED LIVING, INC. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ (Please print name and address) ___________________________________________________________ insert social security or other identifying number ------------------------------------------------------------ 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 numbernumber ------------------------------------------------------------ Dated: ____________________ ___________________________________________________________ (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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Arv Assisted Living Inc)

AutoNDA by SimpleDocs

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo Arch Coal, Inc.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ______________________________________Name:_____________________ (Please print name and address) Address:__________________ ________________________ Social security or taxpayer identification number:___________________ 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 Name:_____________________ Address:__________________ _________________ Social security or other identifying taxpayer identification number: :__________________ Dated:__________________ ___________________________________________________________ Signature (Please print Signature must conform in all respects to name and addressof holder as specified on the face of this Right Certificate) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a member or a participant in Rule 17Ad-15 promulgated under the Securities Transfer Agent Medallion Program, the New York Stock Exchange Act of 1934, as amendedMedallion Signature Program or the Stock Exchange Medallion Program.

Appears in 1 contract

Samples: Rights Agreement (Arch Coal Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Rights Certificate.) ToTO SONIC CORP.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of such Rights (or such other securities 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 share(s) be issued in the name offollowing name: Please insert social security or other identifying number: ___________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: :____________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ Dated: Signature Signature Medallion Guaranteed: :____________ ___________________________________________________ Signatures Signature (Signature must be guaranteed by an “eligible guarantor institution” conform in all respects to name of holder as defined in Rule 17Ad-15 promulgated under specified on the Securities Exchange Act face of 1934, as amended.this Rights Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Sonic Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTO HRG GROUP, INC.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: Please insert Social Security or other identifying number: ___________________________________________________________ . (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security Social Security or other identifying number: ____________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ___________________________________. (Please print name and address) Dated: _________________ ______, _________ Signature (Signature must conform to the holder specified on the Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution” institution (bank, stock broker or savings and loan association with membership in an approved signature medallion program). Form of Reverse Side of Right Certificate -- continued ---------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not Beneficially Owned by, were not acquired by the undersigned from and are not being assigned to an Acquiring Person or an Affiliate or Associate thereof (as such terms are defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedRights Agreement).

Appears in 1 contract

Samples: Rights Agreement (HRG Group, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise any or all Rights evidenced by the Right Rights Certificate.) To: Pericom Semiconductor Corporation Dresser-Rand Group Inc.: The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ (Please print name and address) ___________________________________________________________ ) Rights evidenced by this Rights Certificate to purchase the Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to or that such shares be credited to the book-entry account of: (print social security or other identifying number) (print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert (print social security or other identifying number: ) (print name and address) Dated:_________________________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ Dated, by Name: Title: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a participant in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934Transfer Agent Medallion Program, as amendedthe Stock Exchanges Medallion Program or the New York Stock Exchange, Inc. Medallion Signature Program. A notary public is not sufficient.

Appears in 1 contract

Samples: Rights Agreement (Dresser-Rand Group Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation MANATRON, INC. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such the 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 ofof and delivered to: ________________________Please insert social security or other identifying number: ___________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ____________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ B-8 Dated: Signature Signature Medallion Guaranteed: ______________________________________, 20__ Signatures must be guaranteed Signature Signature Guaranteed: B-9 Certificate The undersigned hereby certifies by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Manatron Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation TO MILLERS AMERICAN GROUP, INC. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of such Rights (or such other securities 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 share(s) be issued in the name offollowing name: Please insert social security or other identifying number: ___________________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this 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) 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 Signature (Signature must be guaranteed by an “eligible guarantor institution” conform in all respects to name of holder as defined in Rule 17Ad-15 promulgated under specified on the Securities Exchange Act face of 1934, as amended.this Right Certificate) Medallion Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Millers Mutual Fire Insurance Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: Pericom Semiconductor Corporation SLH CORPORATION The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: ___________________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ___) _________________ ____________________________________________ (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 print name and addressinsert social security or other identifying number ) ________________ ____________________________________________ (Please print name and address). Dated: Signature Signature Medallion Guaranteed: ______________________ __________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by an eligible guarantor institution” as defined institution (a bank, stockbroker, savings and loan association or credit union with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 promulgated under of the Securities Exchange Act of 1934, . The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as amendeddefined in the Rights Agreement).

Appears in 1 contract

Samples: Rights Agreement (SLH Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo Solitron Devices, Inc.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares Stock issuable upon the exercise of such Rights (or such other securities 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 stock be issued in the name of: ___________________________________________________________ (Please print name and address) _____________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ___________________________________________________________ (Please print name and address) ____________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signature Signature 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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Solitron Devices Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: Pericom Semiconductor Corporation D & K HEALTHCARE RESOURCES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued in the name of: Please insert social security or other identifying number:____________________________________________________ _____________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance 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:_____________________________ Dated: Signature Signature Medallion Guaranteed: _____Signature___________________________________ Signature Guaranteed: Signatures must be guaranteed by a member firm of a registered national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an “eligible guarantor institution” as defined office or correspondent in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedUnited States.

Appears in 1 contract

Samples: Rights Agreement (D & K Healthcare Resources Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor Corporation Micrel, Incorporated The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: _________________________________________________________________________________________ (Please print name and address) _________________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: number ____________________ ______________________________________________________________________ (Please print name and address) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ 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.. The undersigned hereby certifies that:

Appears in 1 contract

Samples: Rights Agreement (Micrel Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To: Pericom Semiconductor To Allmerica Financial Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Rights Certificate to purchase the Preferred Shares number of shares of Common Stock (or other securities) issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: ___________________________________________________________ Please insert social security or other identifying number (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number (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 must conform in all respects to name of holder as specified on the face of this Rights Certificate) Signature Guaranteed: ________________________________________ Signatures :** ** Signature must be guaranteed be a member firm of The New York Stock Exchange, Inc. or a commercial bank or trust company having an office or correspondent in New York City. Certificate The undersigned hereby certifies by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Hanover Insurance Group, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo HearUSA, Inc.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: _______________________________________Name:____________________ (Please print name and address) Address:__________________ _________________________ Social security or taxpayer identification number:__________________ 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 Name:____________________ Address:__________________ __________________ Social security or other identifying taxpayer identification number: :__________________ Dated:__________________ ___________________________________________________________ Signature (Please print Signature must conform in all respects to name and addressof holder as specified on the face of this Right Certificate) ___________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ________________________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a member or a participant in Rule 17Ad-15 promulgated under the Securities Transfer Agent Medallion Program, the New York Stock Exchange Act of 1934, as amendedMedallion Signature Program or the Stock Exchange Medallion Program.

Appears in 1 contract

Samples: Rights Agreement (Hearusa Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: Pericom Semiconductor Corporation Norwalk Savings Society The undersigned hereby irrevocably elects to exercise ___________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such the Rights (or such other securities or property of the Company Bank 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 ofof and delivered to: ___________________________________________________________ (Please print name and address) ___________________________________________________________ insert social security or other identifying number -------------------------------------------------------------------------------- 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) ___________________________________________________________ number -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated: , 19 . ------------------ -- -------------------------------------------------- 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.Signature

Appears in 1 contract

Samples: Rights Agreement (NSS Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by the Right Certificate.) To: Pericom Semiconductor Corporation CAPITOL BANCORP LTD. The undersigned hereby irrevocably elects to exercise Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of such Rights (or such other securities 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 Preferred Shares be issued (or registration for such Preferred Shares be made) in the name of: ___________________________________________Please insert social security or other identifying number ________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying numbernumber __________ (Please print name and address) Dated: ____________________ . ________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by a participant in a Medallion Signature Guarantee Program at a guarantee level acceptable to the Company’s Rights Agent. EXHIBIT B-4 Form of Reverse Side of Right Certificate -- continued The undersigned hereby certifies that the Rights evidenced by this Right Certificate are not Beneficially Owned by an Acquiring Person or an Affiliate thereof (as defined in the Plan). ___________________________________ (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.Signature

Appears in 1 contract

Samples: Benefits Preservation Plan (Capitol Bancorp LTD)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right represented by the Right Certificate.) To: Pericom Semiconductor Corporation Quest Medical, Inc. The undersigned hereby irrevocably elects to exercise _________________ (number) Rights represented by this Right Certificate to purchase the Preferred Common Shares issuable upon the exercise of such Rights (or such other securities 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 Common Shares be issued in the name of: Please print 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 Right Certificate, a new Right Certificate for the balance remaining of such Rights shall will be registered in the name of and delivered to: Please insert print social security or other identifying number: number ____________________ ______________________________________________________________________________ (Please print name and address) ______________________________________________________________________________ Dated: Signature Signature Medallion Guaranteed: ____________________, 19__ ___________________________ Signature Signature Guaranteed: Signatures must be guaranteed by a member firm of a registered national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an “eligible guarantor institution” as defined office or correspondent in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedUnited States.

Appears in 1 contract

Samples: Rights Agreement (Quest Medical Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Rights Certificate.) To: Pericom Semiconductor Corporation To Summit Technology, Inc. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Rights Certificate to purchase the number of one one-thousandths of a share of Preferred Shares Stock (or other securities) issuable upon the exercise of such Rights (or such other securities 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 be issued in the name of: Please insert social security or other identifying number ___________________________________________________________ (Please print name and address) ___________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance 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) If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number ____________________________________________________ ________________________________________________________________________________ (Please print name and address) Dated: Signature Signature Medallion Guaranteed: _______________________, ____ ___________________________________ Signatures Signature (Signature must conform in all respects to name of holder as specified on the face of this Rights Certificate) Signature Guaranteed:** ________________ ** Signature must be guaranteed by an “eligible guarantor institution” as defined "Eligible Guarantor Institution" (with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 promulgated under of 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 (Summit Technology Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) ToTo ALBANY MOLECULAR RESEARCH, INC.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise _______ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such the Rights (or such other securities or property of the Company or of any other Person person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please 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, 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(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: Signature Signature Medallion GuaranteedPlease insert social security or other identifying taxpayer number: ________________________________ _______________________________________________________________________________________ (Please print name and address) Dated: _________, __ ______________________________ Signature Signature Guaranteed: ______________________________ Signatures must be guaranteed by an “eligible guarantor institution” as defined a participant in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amendedMedallion Signature Guarantee Program at a guarantee level acceptable to the Company’s Transfer Agent.

Appears in 1 contract

Samples: Shareholder Rights Agreement (Albany Molecular Research Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right CertificateRights Certificate pursuant to Section 11(a)(ii) of the Rights Agreement.) ToTo ALLIED WASTE INDUSTRIES, INC.: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise shares of such Rights Common Stock (or such other securities or property of the Company or of any other Person which may be Company) issuable upon the exercise of the Rights) Rights and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number -------------------------------------------------------------------------------- The Rights Certificate indicating the balances, if any, of such Rights which may still be exercised pursuant to each of Section 11(a)(ii) and Section 13 of the Rights Agreement shall be returned to the undersigned unless such person requests that the Rights Certificate be registered in the name of and delivered to: Please insert social security or other identifying number (complete only if Rights Certificate is to be registered in a name other than the undersigned) -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated: _________________________________________________________, 20__ (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 73 Certificate The undersigned hereby certifies by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Allied Waste Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of such the Rights (or such other securities 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 be issued in the name ofof 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 Right Rights Certificate, a new Right 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 Medallion Guaranteed: ________________________________________ Signatures must be guaranteed Certificate The undersigned hereby certifies by an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under checking the Securities Exchange Act of 1934, as amended.appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Evergreen Energy Inc)

Time is Money Join Law Insider Premium to draft better contracts faster.