Common use of NOTICE OF EXERCISE Clause in Contracts

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 4 contracts

Samples: Non Qualified Stock Option Agreement (Aspen Group, Inc.), Non Qualified Stock Option Agreement (Aspen Group, Inc.), Non Qualified Stock Option Agreement (Aspen Group, Inc.)

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NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on October 5, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________representing the aggregate exercise price for such Units. The undersigned hereby represents and warrants to the Company that it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, _______________ Facsimile: as amended (____) _____-______ Please the “Securities Act”), and is acquiring these securities for its own account and not with a view to, or for sale in connection with, any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares it will be advised receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that I hereby elect to exercise my option to purchase under such laws, such shares of ___________, may only be sold pursuant to an effective and current registration statement under the Stock Option Agreement dated __________________Securities Act or an exemption from the registration requirements of the Securities Act and any other applicable restrictions, in which event a legend or legends will be placed upon the certificate(s) representing the Units issuable under this Warrant denoting such restrictions. Number The undersigned understands and acknowledges that the Company will rely on the accuracy of Shares to Be Purchasedthese representations and warranties in issuing the securities underlying the Warrant. [warrant notice of exercise signature page] Date: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderWarrant Holder Name: __________________________________________________________ Social Security Number of Option HolderTaxpayer Identification Number: ____________________________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personBy: ________________________________ (Name) _________________________________________________ (Address) Printed Name: _________________________________________________________________ Title: ________________________________________________________________________ Address: ________________________________________________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection Note: The above signature should correspond exactly with the issuance name on the face of this Warrant or with the Common Stockname of assignee appearing in assignment form below. AND, if said number of shares shall be less than the Common Stock may not be immediately publicly sold, I hereby represent to total number of shares purchasable under the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection withWarrant, a distribution new Warrant is to be issued in the name of said undersigned for the balance remaining of the shares within purchasable thereunder less any fraction of a share paid in cash and delivered to the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderaddress stated above.

Appears in 4 contracts

Samples: Lifesciences Opportunities Inc, Lifesciences Opportunities Inc, Lifesciences Opportunities Inc

NOTICE OF EXERCISE. (Complete and sign only upon exercise of the Common Stock Purchase Warrant in whole or in part.) To: _________________EVO Transportation & Energy Services, Inc. The undersigned, the holder of the attached Common Stock Purchase Warrant to which this Notice of Exercise applies (the “Warrant”), hereby irrevocably elects to exercise pursuant to Section 2.1 of the Warrant and to purchase _________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________from EVO Transportation & Energy Services, 20__. Please contact me as soon as possible to discuss the possible Inc. and herewith makes payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ____$____________________________ Address of Option Holder therefor in cash or by certified or official bank check. The undersigned hereby requests that such securities be issued in the name(s) and delivered to the address(es) as follows: Name: ________________________________________________________________________ Telephone Number of Option HolderAddress: ______________________________________________________________________ Social Security Number of Option HolderNumber: __________________________________________________________ Deliver to: _____________________________________________________________________ Address: ______________________________________________________________________ If the certificate foregoing evidences an exercise of the Warrant to purchase fewer than all of the shares of Common Stock to which the undersigned is to be issued to person other than the Option Holderentitled under such warrant, please provide issue a new warrant, of like tenor, relating to the following for remaining portion of the securities issuable upon exercise of such personwarrant in the name(s), and deliver the same to the address(es), as follows: Name: ________________________________ (Name) _________________________________________ (Address) : ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: ________________________________________________________________________ Signature (Name of Option Warrant Holder) (Social Security or Taxpayer Identification Number of Warrant Holder, if applicable)

Appears in 3 contracts

Samples: EVO Transportation & Energy Services, Inc., EVO Transportation & Energy Services, Inc., EVO Transportation & Energy Services, Inc.

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on July 20, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________representing the aggregate exercise price for such Unitss. The undersigned hereby represents and warrants to the Company that it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, _______________ Facsimile: as amended (____) _____-______ Please the “Securities Act”), and is acquiring these securities for its own account and not with a view to, or for sale in connection with, any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares it will be advised receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that I hereby elect to exercise my option to purchase under such laws, such shares of ___________, may only be sold pursuant to an effective and current registration statement under the Stock Option Agreement dated __________________. Number Securities Act or an exemption from the registration requirements of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes Securities Act and any other documents we may requireapplicable restrictions, in which event a legend or legends will be placed upon the certificate(s) representing the Units issuable under this Warrant denoting such restrictions. Name The undersigned understands and acknowledges that the Company will rely on the accuracy of Option these representations and warranties in issuing the securities underlying the Warrant. [warrant notice of exercise signature page] Date: Warrant Holder (Please Print): ________________________________ Address Name: Taxpayer Identification Number: By: Printed Name: Title: Address: Note: The above signature should correspond exactly with the name on the face of Option this Warrant or with the name of assignee appearing in assignment form below. AND, if said number of shares shall be less than the total number of shares purchasable under the Warrant, a new Warrant is to be issued in the name of said undersigned for the balance remaining of the shares purchasable thereunder less any fraction of a share paid in cash and delivered to the address stated above. ASSIGNMENT FORM To be executed by the Warrant Holder ____________________________In order to Assign Warrants FOR VALUE RECEIVED,____________________________________ Telephone Number of Option Holder: hereby sell, assigns and transfer unto PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER (Please print or type name and address) ______________________ of the Warrants represented by this Warrant, and hereby irrevocably constitutes and appoints ________________________ Social Security Number Attorney to transfer this Warrant on the books of Option the Company, with full power of substitution in the premises. Dated: (Signature of Registered Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection addition to executing this Assignment Form, the Warrant Holder and the transferee must comply with the issuance other requirements for transfer set forth in Sections 6 and 7 of the Common Stock, if the Common Stock may not be immediately publicly sold, I Warrant. CERTIFICATION OF STATUS OF TRANSFEREE TO BE EXECUTED BY THE TRANSFEREE OF THIS WARRANT The undersigned transferee hereby represent certifies to the Company registered holder of this Warrant and to DR. TATTOFF, LLC that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares transferee is an “accredited investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933 (the “Securities Act”)1933, as amended. I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ (Signature of Option HolderTransferee)

Appears in 3 contracts

Samples: Lifesciences Opportunities Inc, Lifesciences Opportunities Inc, Dr. Tattoff, Inc.

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on July 23, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________representing the aggregate exercise price for such Units. The undersigned hereby represents and warrants to the Company that it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, _______________ Facsimile: as amended (____) _____-______ Please the “Securities Act”), and is acquiring these securities for its own account and not with a view to, or for sale in connection with, any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares it will be advised receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that I hereby elect to exercise my option to purchase under such laws, such shares of ___________, may only be sold pursuant to an effective and current registration statement under the Stock Option Agreement dated __________________Securities Act or an exemption from the registration requirements of the Securities Act and any other applicable restrictions, in which event a legend or legends will be placed upon the certificate(s) representing the Units issuable under this Warrant denoting such restrictions. Number The undersigned understands and acknowledges that the Company will rely on the accuracy of Shares to Be Purchasedthese representations and warranties in issuing the securities underlying the Warrant. [warrant notice of exercise signature page] Date: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderWarrant Holder Name: __________________________________________________________ Social Security Number of Option HolderTaxpayer Identification Number: ____________________________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personBy: ________________________________ (Name) _________________________________________________ (Address) Printed Name: _________________________________________________________________ Title: ________________________________________________________________________ Address: ________________________________________________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection Note: The above signature should correspond exactly with the issuance name on the face of this Warrant or with the Common Stockname of assignee appearing in assignment form below. AND, if said number of shares shall be less than the Common Stock may not be immediately publicly sold, I hereby represent to total number of shares purchasable under the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection withWarrant, a distribution new Warrant is to be issued in the name of said undersigned for the balance remaining of the shares within purchasable thereunder less any fraction of a share paid in cash and delivered to the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderaddress stated above.

Appears in 2 contracts

Samples: Lifesciences Opportunities Inc, Lifesciences Opportunities Inc

NOTICE OF EXERCISE. To(To be executed by the Holder to exercise the right to purchase shares of Common Stock under the foregoing Stock Purchase Warrant) To X.X. XXXXXXXX & CO., INC.: In accordance with the Warrant enclosed with this Notice of Exercise, the undersigned hereby irrevocably elects to purchase ___________________shares of common stock, $0.01 par value per share, of X.X. XXXXXXXX & CO., INC. (the "Common Stock") and encloses herewith $_______ __________________________ __________________________ Attention _________in cash, _______________ Facsimile: certified or official bank check or checks, which sum represents the aggregate Exercise Price (____as defined in the Stock Purchase Warrant) _____-______ Please be advised that I hereby elect to exercise my option to purchase for the number of shares of ___________, Common Stock to which this Notice of Exercise relates together with any applicable taxes payable by the undersigned pursuant to the Stock Option Agreement dated __________________Purchase Warrant. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check The undersigned requests the payment method below: ____ Enclosed is a check certificates for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss shares of Common Stock issuable upon this exercise in the possible payment name of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address . XXXXX INSERT SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER -------------------------------- ------------------------------------------------------------------------------- (Please print name and address) If the number of Option Holder ___________________________________________________shares of Common Stock issuable upon this exercise shall not be all of the shares of Common Stock which the undersigned is entitled to purchase in accordance with the enclosed Stock Purchase Warrant, the undersigned requests that a new Stock Purchase Warrant evidencing the right to purchase the shares of Common Stock not issuable pursuant to the exercise evidenced hereby be issued in the name of and delivered to: ------------------------------------------------------------------------------- (Please print name and address) Dated:_____________ Telephone Number Name of Option HolderXxxxxx: ________________________________ Social Security Number -------------------------------------- (Print) By: ----------------------------------- Name: Title: (Signature must conform in all respects to name of Option Holder: ________________________________ If holder as specified on the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance face of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”Purchase Warrant). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 2 contracts

Samples: Meyerson M H & Co Inc /Nj/, Leighton John P

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderHolder Exhibit A

Appears in 2 contracts

Samples: Non Qualified Stock Option Agreement (GelTech Solutions, Inc.), Non Qualified Stock Option Agreement (GelTech Solutions, Inc.)

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of exercise ____________ shares of Stock Appreciation Rights, pursuant to the Stock Option Appreciation Rights Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__2012. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Optionssecurities, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options securities shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderHolder Exhibit A

Appears in 2 contracts

Samples: Stock Appreciation Rights Agreement (GelTech Solutions, Inc.), Stock Appreciation Rights Agreement (GelTech Solutions, Inc.)

NOTICE OF EXERCISE. To: The undersigned hereby irrevocably elects to exercise [__________________________ __________________________ __________________________ Attention _________] of the Warrants represented by this Warrant Certificate and purchase the whole number of Units issuable and deliverable upon exercise of such Warrants, _______________ Facsimile: (____) _____-______ Please and herewith tenders payment for such Units in accordance with the terms of the Warrant Agreement. The undersigned hereby directs that the certificate or certificates for the Units issuable and deliverable upon exercise, together with any check in payment for fractional Units and any Warrant Certificate representing any unexercised Warrants represented by this Warrant Certificate, be advised that I hereby elect to exercise my option to purchase shares issued in the name of ___________, pursuant and delivered to the Stock Option Agreement dated __________________undersigned, unless a different name is indicated below. Number The undersigned will pay any transfer taxes or other governmental charge payable with respect to any such Units to be issued in the name of Shares to Be Purchaseda person other than the undersigned. INSTRUCTIONS FOR REGISTRATION OF UNITS (please typewrite or print) Name: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: Address:_______________________________________________________________ Social Security Number or Other Taxpayer Identification Number: ______________ Dated: ____________________ Signature: ________________ Note: Signature must conform to name of Option Holder appearing on face hereof) Signature must be guaranteed by a member of an accepted medallion guarantee program if Units are to be issued, or Warrant Certificate(s) are to be delivered, other than to and in the name of the Holder. ___________________________________ Signature Guarantee Fill in for registration of Units and Warrant Certificate(s) if to be issued otherwise than to the Holder: ________________________________ If the certificate is to be issued to person Social Security or other than the Option Holder, please provide the following for such person(Name) Taxpayer Identification Number: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________ Please print name and address (including zip code) EXHIBIT B TRANSFER INSTRUCTION RE: ARBOR REALTY LIMITED PARTNERSHIP WARRANTS Reference is made to the Warrant Agreement dated as of July 1, 2003, relating to the Warrants (the "Agreement"). This Instruction and Certification relates to Warrants held by ___________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”"Transferor/Holder"). I am______ am Capitalized terms not ______ [please initial one] an accredited investor for at least one otherwise defined herein have the meanings set forth in the Agreement. Instruction of Transfer or Exchange (to be completed whether or not the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall Warrants to be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holdertransferred or exchanged are Transfer Restricted Warrants)

Appears in 1 contract

Samples: Warrant Agreement (Arbor Realty Trust Inc)

NOTICE OF EXERCISE. ToTo Be Executed by the Registered Holder in Order to Exercise Warrants The undersigned Registered Holder irrevocably elects to exercise ______________ Warrants represented by this Warrant Certificate, and to purchase the Shares issuable upon the exercise of such Warrants, using the Cashless Exercise method, resulting in the issuance of ______ Shares to the undersigned. The undersigned has calculated the number of Shares to be issued to it in accordance with the following formula set forth in Section 1(d) of the Warrant: X = Y[(A - B)/A] X = the number of Shares to be issued to the Holder Y = the number of Shares with respect to which this Warrant is being exercised A = the Fair Market Value of one Share B = the Warrant Price Where the Fair Market Value of one Share is $[__], being the [average closing price or last sale price of the Shares reported for the five (5) business days prior to the applicable date of determination][last sale price of the Shares for the business day immediately prior to the applicable date of determination] The undersigned requests that Certificates for such shares shall be issued in the name of __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: and be delivered to ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (NamePLEASE PRINT OR TYPE NAME AND ADDRESS) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stockand, if the Common Stock may such number of Warrants shall not be immediately publicly soldall the Warrants evidenced by this Warrant Certificate, I hereby represent to that a new Warrant Certificate for the Company that I am acquiring balance of such Warrants be registered in the Common Stock for my own account for investment name of, and not with a view delivered to, or for resale in connection with, a distribution of the shares within Registered Holder at the meaning of the Securities Act of 1933 (the “Securities Act”)address stated below. I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderBy: Name: Title: (ADDRESS AND EMAIL) (TAX IDENTIFICATION NUMBER)

Appears in 1 contract

Samples: Dragonfly Energy Holdings Corp.

NOTICE OF EXERCISE. (Complete and sign only upon exercise of the Common Stock Purchase Warrant in whole or in part.) To: ________________OrangeHook, Inc. The undersigned, the holder of the attached Common Stock Purchase Warrant to which this Notice of Exercise applies (the "Warrant"), hereby irrevocably elects to exercise the purchase rights represented by such warrant as follows: the undersigned requests to exercise on a cashless basis pursuant to Section 2.5 of the Warrant, and such exercise will be with respect to __________ _________________shares of Warrant Stock available for exercise under the Warrant. the undersigned elects to exercise pursuant to Section 2.1 of the Warrant and to purchase _________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________from OrangeHook, 20__. Please contact me as soon as possible to discuss the possible Inc. and herewith makes payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ____$____________________________ Address of Option Holder therefor in cash or by certified or official bank check. The undersigned hereby requests that the certificate(s) representing such securities be issued in the name(s) and delivered to the address(es) as follows: Name: ________________________________________________________________________ Telephone Number of Option HolderAddress: ______________________________________________________________________ Social Security Number of Option HolderNumber: ___________________________________________________________ Deliver to: _____________________________________________________________________ Address: ______________________________________________________________________ If the certificate foregoing evidences an exercise of the Warrant to purchase fewer than all of the shares of Common Stock to which the undersigned is to be issued to person other than the Option Holderentitled under such warrant, please provide issue a new warrant, of like tenor, relating to the following for remaining portion of the securities issuable upon exercise of such personwarrant in the name(s), and deliver the same to the address(es), as follows: Name: ________________________________ (Name) _________________________________________ (Address) : ______________________________________________________________________ Dated: ________________________________________________________________________ ________________________________ ______________________________________________ (Telephone NumberName of Warrant Holder) ________________________________ (Social Security Number) In connection with the issuance or Taxpayer Identification Number of the Common StockWarrant Holder, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”applicable). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 1 contract

Samples: Participation and Repayment Priority Agreement (Orangehook, Inc.)

NOTICE OF EXERCISE. To: This Notice of Exercise shall constitute proper notice pursuant to Section 1.8 of that certain Stock Option Agreement (the "Agreement") dated as of ___________, 200___, between True Religion Apparel, Inc. (the "Company") and the undersigned. The undersigned hereby elects to exercise Optionee's option to purchase ____________________ _____________________shares of the common stock of the Company at a price of US$_____ __________________________ Attention ____per share, for aggregate consideration of US$_____, _______________ Facsimileon the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 1.8 of the Agreement, accompanies this notice. The Optionee hereby directs the Company to issue, register and deliver the certificates representing the shares as follows: (____) _____-______ Please be advised that I hereby elect Registration Information: Delivery Instructions: Name to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. appear on certificates Name Address Address Telephone Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): DATED at ____________________________________, the ________ Address day of Option Holder _____________________, _______. _________________________________________ Telephone Number (Name of Option Holder: Optionee - Please type or print) ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (NameSignature and, if applicable, Office) _________________________________________ (AddressAddress of Optionee) ________________________________ ________________________________ ________________________________ (Telephone NumberCity, State, and Zip Code of Optionee) _________________________________________ (Social Security Fax Number) In connection with EXHIBIT B ACCREDITED INVESTOR QUESTIONNAIRE All capitalized terms herein, unless otherwise defined, have the issuance of meanings ascribed thereto in the Common StockAgreement. The Optionee covenants, if the Common Stock may not be immediately publicly sold, I hereby represent represents and warrants to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, it satisfies one or for resale in connection with, a distribution more of the shares within categories of "Accredited Investors", as defined by Regulation D promulgated under the meaning 1933 Act, as indicated below: (Please initial in the space provide those categories, if any, of an "Accredited Investor" which the Securities Act of 1933 (the “Securities Act”). I amOptionee satisfies) ______ am not ______ [please initial one] an accredited investor for at least one Category 1 An organization described in Section 501(c)(3) of the reasons on United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the attached Exhibit A. If specific purpose of acquiring the SEC has amended the rule defining the definition Units, with total assets in excess of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderUS $5,000,000;

Appears in 1 contract

Samples: Employee Stock Option and Subscription Agreement (True Religion Apparel Inc)

NOTICE OF EXERCISE. To: __________This Notice of Exercise shall constitute proper notice pursuant to Section 1.8 of that certain Stock Option Agreement (the "Agreement") dated as of December 16, 2004, between Bulldog Technologies Inc. (the "Company") and the undersigned. The undersigned hereby elects to exercise Optionee's option to purchase ________________ shares of the common stock of the Company at a price of US$1.60 per share, for aggregate consideration of US$__________________________ __________________________ Attention _________, _______________ Facsimileon the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 1.8 of the Agreement, accompanies this notice. The Optionee hereby directs the Company to issue, register and deliver the certificates representing the shares as follows: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be PurchasedRegistration Information: Delivery Instructions: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________________ Name to appear on certificates Name ________________________________________ ________________________________________ Address Address ________________________________________ ________________________________________ ________________________________________ ________________________________________ Telephone Number DATED at ____________________________________, the ________ day of __________________, _______. ________________________________________ (Telephone NumberName of Optionee - Please type or print) ________________________________________ (Social Security Number) In connection with the issuance of the Common StockSignature and, if the Common Stock may not be immediately publicly soldapplicable, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I amOffice) ______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: (Address of Optionee) ________________________________________ Signature (City, State, and Zip Code of Option HolderOptionee) ________________________________________ (Fax Number) EXHIBIT B ACCREDITED INVESTOR QUESTIONNAIRE All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the Agreement. The Optionee covenants, represents and warrants to the Company that it satisfies one or more of the categories of "Accredited Investors", as defined by Regulation D promulgated under the 1933 Act, as indicated below: (Please initial in the space provide those categories, if any, of an "Accredited Investor" which the Optionee satisfies) ______ Category 1 An organization described in Section 501(c)(3) of the United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the specific purpose of acquiring the Units, with total assets in excess of US $5,000,000;

Appears in 1 contract

Samples: Option and Subscription Agreement (Bulldog Technologies Inc)

NOTICE OF EXERCISE. To: __________________The undersigned hereby irrevocably elects to exercise ________ __________________________ __________________________ Attention _________of the Warrants represented by this Warrant Certificate and purchase the whole number of shares issuable and deliverable upon exercise of such Warrants, _______________ Facsimile: (____) _____-______ Please and herewith tenders payment for such shares in accordance with the terms of the Warrant Agreement. The undersigned hereby directs that the certificate or certificates for the shares issuable and deliverable upon exercise, together with any check in payment for fractional shares and any Warrant Certificate representing any unexercised Warrants represented by this Warrant Certificate, be advised that I hereby elect to exercise my option to purchase shares issued in the name of ___________, pursuant and delivered to the Stock Option Agreement dated __________________undersigned, unless a different name is indicated below. Number The undersigned will pay any transfer taxes or other governmental charge payable with respect to any such shares to be issued in the name of Shares to Be Purchaseda person other than the undersigned. INSTRUCTIONS FOR REGISTRATION OF SHARES (please typewrite or print) Name: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderAddress: ______________________________________________________________ Social Security Number or Other Taxpayer Identification Number: ______________ Dated: ____________________ Signature: ___________________________ Note: Signature must conform to name of Option Holder appearing on face hereof) Signature must be guaranteed by a member of an accepted medallion guarantee program if shares of Common Stock are to be issued, or Warrant Certificate(s) are to be delivered, other than to and in the name of the Holder. ______________________ Signature Guarantee Fill in for registration of shares of Common Stock and Warrant Certificate(s) if to be issued otherwise than to the Holder: ____________________________________ If the certificate is to be issued to person Social Security or other than the Option Holder, please provide the following for such person(Name) Taxpayer Identification Number: ____________________________________ ______________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ _____Please print name and address (including zip code) EXHIBIT B TRANSFER INSTRUCTION RE: ARBOR REALTY TRUST, INC. WARRANTS Reference is made to the Warrant Agreement dated as of July 1, 2003, relating to the Warrants (the "Agreement"). This Instruction and Certification relates to Warrants held by ___________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”"Transferor/Holder"). I am______ am Capitalized terms not ______ [please initial one] an accredited investor for at least one otherwise defined herein have the meanings set forth in the Agreement. Instruction of Transfer or Exchange (to be completed whether or not the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall Warrants to be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holdertransferred or exchanged are Transfer Restricted Warrants)

Appears in 1 contract

Samples: Warrant Agreement (Arbor Realty Trust Inc)

NOTICE OF EXERCISE. ToSibyte, Inc. ---------------------------------- ---------------------------------- Attn: __________________________ __________________________ __________________________ Attention _________, _______________ FacsimileChief Financial Officer Re: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares Exercise of ___________, pursuant Stock Option Dear Sir or Madam: Pursuant to the Stock Option Agreement dated __________, 199________. Number of Shares _ (the "Stock Option Agreement") and the Company's 1998 Stock Incentive Plan (the "Plan"), I hereby elect to Be Purchased: __purchase _____________ Multiplied by: Purchase Price Per Share shares of the Common Stock of the Company at aggregate exercise price of $__________. I enclose payment and other documents (check all that are applicable): [ ] My check in the amount of $______________ Total Purchase Price $_______________ Please check ; [ ] If I am exercising an unvested option, I also enclose an executed Assignment Separate From Certificate. The Common Stock is to be issued and registered in the payment method belowname(s) of: ____ Enclosed -------------------------- -------------------------- I understand that there may be tax consequences as a result of the purchase or disposition of the Common Stock, and I have consulted with any tax consultants I wished to consult and I am not relying on the Company for any tax advice. I understand that my exercise is governed by my Stock Option Agreement and the Plan and agree to abide by and be bound by their terms and conditions. I represent that the Common Stock is being acquired solely for my own account and not as a check nominee for any other party, or for investment, and that I will not offer, sell or otherwise dispose of any such Common Stock except under circumstances that will not result in a violation of the total purchase price aboveSecurities Act of 1933, as amended, or any state securities laws. ____ Wire transfer sent on ___Dated: __________, 20199__ ----------------------------------------- (Signature) ----------------------------------------- (Please Print Name) ----------------------------------------- ----------------------------------------- (Address) ASSIGNMENT SEPARATE FROM CERTIFICATE FOR VALUE RECEIVED and pursuant to that certain Stock Option Agreement dated as of __. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________, 199__, the undersigned hereby sells, assigns and transfers unto ______________________________ Address of Option Holder (__________) shares of the Common Stock of Tharas Systems, Inc., a Delaware corporation, standing in the undersigned's name on the books of said corporation represented by certificate No. _______________ herewith, and does hereby irrevocably constitute and appoint ________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If attorney to transfer the certificate is to be issued to person other than said stock on the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance books of the Common Stock, if said corporation with full power of substitution in the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”)premises. I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: __________, 19_______ Signature of Option Holder. ----------------------------------------- Signature

Appears in 1 contract

Samples: Stock Option Agreement (Broadcom Corp)

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: PC Universe, Inc. The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ shares of the common stock, par value $.001 per share (“Common Stock”), of PC Universe, Inc., pursuant to Warrant No. ___ heretofore issued to ___________________ on ____________, 2007; (2) encloses a cash payment of $__________; or (3) surrenders shares of Common Stock or Warrant Shares pursuant to the cashless exercise procedure provided for in the following paragraph; and (4) requests that a certificate for the Warrant Shares be issued in the name of the undersigned, or the undersigned's designee, and delivered to the undersigned, or the undersigned's designee, at the address specified below. The undersigned hereby elects to subscribe for Warrant Shares by cashless exercise of the Warrant in accordance with Section 2.1(b) of the Warrant, and indicates below the number of shares of Common Stock or Warrant Shares to be surrendered and provides the calculation (pursuant to Section 2.1(b)(i) or (ii) of the Warrant) for the number of shares to be surrendered: Number of shares to be Surrendered: __________________________ __Calculation Pursuant to Section 2.1(b): ________________________ __________________________ Attention _________The undersigned hereby represents and warrants to the Company that it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, _______________ Facsimile: as amended (____) _____-______ Please be advised the “Securities Act”), and is acquiring these securities for its own account and not with a view to, or for sale in connection with, any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that I hereby elect it does not have any contract, agreement, understanding or arrangement with any person to exercise my option to purchase sell, transfer or grant the shares of ___________Common Stock issuable under this Warrant. The undersigned understands that the shares it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from PC Universe, Inc., in transactions not including any public offering and that under such laws, such shares may only be sold pursuant to an effective and current registration statement under the Securities Act or an exemption from the registration requirements of the Securities Act and any other applicable restrictions, in which event a legend or legends will be placed upon the certificate(s) representing the Common Stock Option Agreement dated __________________issuable under this Warrant denoting such restrictions. Number The undersigned understands and acknowledges that the Company will rely on the accuracy of Shares to Be Purchasedthese representations and warranties in issuing the securities underlying the Warrant. [warrant notice of exercise signature page] Date: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderInvestor Name: _________________________________________________________________ Social Security Number of Option HolderTaxpayer Identification Number: ____________________________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personBy: ________________________________ (Name) _________________________________________________ (Address) Printed Name: _________________________________________________________________ Title: ________________________________________________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderAddress:

Appears in 1 contract

Samples: Pc Universe Inc

NOTICE OF EXERCISE. To(To be signed upon exercise of Warrant) The Undersigned, the holder of the within Warrant, hereby irrevocably elects to exercise the purchase right represented by such Warrant for, and to purchase thereunder, of the shares of common stock of Webdigs, Inc. to which such Warrant relates and herewith makes payment of $______________________ therefor in cash or by certified check (unless the Warrant is being exercised pursuant to Section 9, in which case the box below indicating such fact is checked), and requests that the certificate for such shares be issued in the name of, and be delivered to, ________________________ the address for which is set forth below the signature of the undersigned.  The undersigned is exercising the Warrant pursuant to the Net Issue Exercise provisions of Section 9. Dated: _______________________, 20____ Signature Name Address City, State, Zip Code Social Security or Tax Identification No. ASSIGNMENT FORM (To be signed only upon authorized transfer of Warrant) For Value Received, the undersigned hereby sells, assigns, and transfers unto __________________________ the right to purchase the securities of Webdigs, Inc., a Delaware corporation, to which the within Warrant relates and appoints __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect attorney, to exercise my option to purchase shares transfer said right on the books of ___________Webdigs, pursuant to Inc. with full power of substitution in the Stock Option Agreement dated __________________premises. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderDated: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _____________20____ Signature of Option HolderName Address Social Security or Tax Identification No.

Appears in 1 contract

Samples: Webdigs Inc

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. ____ Cashless exercise Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stockcommon stock, if the Common Stock common stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock common stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 1 contract

Samples: Non Qualified Stock Option Agreement (TimefireVR Inc.)

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________The undersigned, _______________ Facsimile: (____) _____-______ Please be advised that I the Holder of the foregoing Warrant, hereby elect to exercise my option to purchase shares of ___________irrevocably elects, pursuant to Section 3 of the Warrant, to exercise purchase rights represented by such Warrant for, and to purchase thereunder, shares of the Common Stock Option Agreement dated __________________. Number of Shares Xxxxxxxx Petroleum Corporation (the ------------- "Company") to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible which such Warrant relates and herewith makes payment of withholding taxes $ therefor, as follows: ---------------------- $ in cash, ----------------------- $ by wire transfer to the Company, ----------------------- $ by certified check or money order, or ----------------------- $ by cancellation of accrued interest, ----------------------- first, and then outstanding principal under the Secured Notes, and requests that certificates for such shares (and any other documents we may requiresecurities or property deliverable upon such conversion including a revised warrant) be delivered to the undersigned at the address set forth below the signature of the undersigned. Dated: ---------------------- Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number --------------------------------------------------- By: ----------------------------------------------- (Signature of Option HolderAuthorized Officer) Title: ________________________________ If ----------------------------------------------- Address: -------------------------------------------------- -------------------------------------------------- -------------------------------------------------- APPENDIX B NOTICE OF CONVERSION The undersigned, the certificate is Holder of the foregoing Warrant, hereby elects pursuant to be issued Section 7 of the Warrant, to person other than convert the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance rights to purchase -------- shares of the Common StockStock covered by such Warrant and herewith makes payment in full therefor by surrender of such Warrant, if and requests that certificates for the Common Stock may not appropriate number of shares (and any other securities or property deliverable upon such conversion including a revised warrant) be immediately publicly sold, I hereby represent to issued in the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution name of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”)undersigned and delivered to its address as set forth below. I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ ---------------------- Name of Holder: --------------------------------------------------- By: ----------------------------------------------- (Signature of Option HolderAuthorized Officer) Title: ----------------------------------------------- Address: -------------------------------------------------- -------------------------------------------------- --------------------------------------------------

Appears in 1 contract

Samples: Goodrich Petroleum Corp

NOTICE OF EXERCISE. To(To be executed upon exercise of this Warrant) The undersigned hereby irrevocably elects to exercise the right represented by this Warrant to purchase _________ shares of Common Stock, and herewith tenders to the Company as payment for such shares either (a) the amount of $__________ or (b) ________ shares of Common Stock, in accordance with the terms of this Warrant. The undersigned requests that a certificate for such shares be registered in the name of the undersigned and that such certificates be delivered to the undersigned's address below. The undersigned represents that it is an accredited and sophisticated investor (as defined in applicable rules and regulations under the Securities Act of 1933, as amended), and that it is acquiring such shares of Common Stock for its own account for investment and not with a view to or for sale in connection with any distribution thereof. Dated: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ Signature ________________________________ ________________________________ (Telephone NumberPrint Name) ________________________________ (Social Security NumberXxxxxx Xxxxxxx) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature (City) (State) (Zip Code) ================================================================================ ANNEX II --------------- DETERMINATION OF REVENUE This Annex II contains the criteria used to determine the Vesting Multiplier for purposes of Option HolderSection 2.4 of the Warrant issued by e-centives, Inc., a Delaware corporation (the "COMPANY"), in favor of Inktomi Corporation, a Delaware corporation (the "WARRANTHOLDER"), to which this Annex II is attached. Any capitalized term not defined in this Annex II shall have the meaning assigned to the term in the Warrant. For the Vesting Multiplier to be greater than 0, both the relevant Revenues Test and the Product Performance Test set forth below must be met during the Warrant Period. Notwithstanding anything herein to the contrary, the Company agrees to operate the Business in good faith and will take no action to circumvent the Earnout.

Appears in 1 contract

Samples: E Centives Inc

NOTICE OF EXERCISE. ToTO: ORAGENICS, INC. The undersigned is the Holder of Warrant No. _____ (the "Warrant") issued by Oragenics, Inc., a Florida Corporation (the "Company"). Capitalized terms used herein and not otherwise defined have the respective meanings set forth in the Warrant. The Warrant is currently exercisable to purchase a total of ______ Warrant Shares. The undersigned hereby exercises its right to purchase _________ Warrant Shares pursuant to the Warrant and delivers herewith the original Warrant certificate in accordance with the terms of the Warrant and tenders herewith payment of the exercise price in full, together with all applicable transfer taxes, if any. Payment shall take the form of (check applicable box): [ ] in lawful money of the United States; or [ ] the cancellation of such number of Warrant Shares as is necessary, in accordance with the formula set forth in Section 1(b) of the Warrant, to exercise this Warrant with respect to the maximum number of Warrant Shares purchasable pursuant to the cashless exercise procedure set forth in Section 1(b) of the Warrant. The undersigned hereby requests that the Company issue a certificate or certificates representing said Warrant Shares in the name of the undersigned or in such other name as is specified below: The Warrant Shares shall be delivered to the following: _________________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address Accredited Investor. The undersigned is an "accredited investor" as defined in Regulation D promulgated under the Securities Act of Option Holder 1933, as amended. Name of Holder: _________________________________________________________________ Signature of Authorized Signatory of Holder: ________________________________________________________________________ Name of Authorized Signatory: ______________________________________________________ Title of Authorized Signatory: ______________________________________________________________________ Telephone Number and E-Mail Address of Option HolderAuthorized Signatory: ______________________________________________________________________ Social Security Number of Option HolderDate: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ___________________________________________ (NameSignature must conform in all respect to the name of Holder as specified on the face of the Warrant.) ASSIGNMENT FORM (TO ASSIGN THE FOREGOING WARRANT, EXECUTE THIS FORM AND SUPPLY REQUIRED INFORMATION. DO NOT USE THIS FORM TO EXERCISE THE WARRANT.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby sold, assigned and transferred to _______________________________ whose address is ___________________________________________________________, and _______________________ is hereby appointed attorney to transfer said rights on the books of Oragenics, Inc., with full power of substitution in the premises. Dated: ___________________________ Holder's Signature: _________________________________________ (Holder's Address) : ______________________________________ ______________________________________ Signature Guaranteed: ________________________________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection NOTE: The signature to this Assignment Form must correspond with the issuance name as it appears on the face of the Common StockWarrant, if without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderforegoing Warrant.

Appears in 1 contract

Samples: Securities Purchase Agreement (Oragenics Inc)

NOTICE OF EXERCISE. ToTO: LEXARIA BIOSCIENCE CORP. (the “Corporation”) Capitalized terms not defined herein have the meaning set out in Warrant Certificate No. 2018-10-XX of the Corporation dated October 31, 2018 (the “Warrant Certificate”). The undersigned holder of the Warrants represented by the enclosed Warrant Certificate hereby exercises the right provided for in the Warrants to purchase ___________ Common Shares in the capital of the Corporation issuable on the exercise of the Warrants and encloses the amount of US$2.25 per Common Share (or the adjusted Exercise Price at which the undersigned is entitled to purchase such shares as provided in this Warrant Certificate) by way of certified cheque or recognized bank draft made payable to or to the order of the Corporation. Subject to certain limited exceptions, (i) the Warrants may not be exercised within the “United States”, or by or for the account or benefit of a person in the “United States” or a “U.S. Person” (as such terms are defined in Rule 902 of Regulation S promulgated under the United States Securities Act of 1933, as amended), and (ii) no Common Shares issuable upon exercise of the Warrants will be delivered to any address in the United States. The undersigned hereby irrevocably directs that such Common Shares be issued and delivered as follows: Name(s) in Full Address(es)* Number(s) of Common Shares _________________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) _________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: ________________________________ Please print in full the name in which certificates are to be issued. DATED this ____ day of _______, 20__. ______________________________ __________________________ Witness Signature of Option HolderHolder __________________________ Name of Holder __________________________ __________________________ Address of Holder ☐ Please check box if these certificates are to be delivered to the office where this Warrant Certificate is surrendered, failing which the certificate

Appears in 1 contract

Samples: Lexaria Bioscience Corp.

NOTICE OF EXERCISE. To: To Be Executed by the Registered Holder in Order to Exercise Warrants The undersigned Registered Holder hereby irrevocably elects to exercise ______________________ Warrants represented by this Warrant Certificate, and to purchase the securities issuable upon the exercise of such Warrants, and requests that certificates for such securities shall be issued in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER _______________________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ _______________________________________ [please print or type name and address] and be delivered to _______________________________________ _______________________________________ _______________________________________ _______________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant Certificate for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. ____________________________________ (Name of NASD Member) Dated: ______________________ X______________________ _________________ __________________ Address ______________________ Taxpayer Identification Number ____________________ ASSIGNMENT To Be Executed by the Registered Holder in Order to Assign Warrants FOR VALUE RECEIVED, ___________________ hereby sells, assigns and transfers unto PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER _______________________________________ _______________________________________ _______________________________________ _______________________________________ [please print or type name and address] _________________________ of Option Holder the Warrants represented by this Warrant Certificate, and hereby irrevocably constitutes and appoints ___________________________________________________________________ Telephone Number Attorney to transfer this Warrant Certificate on the books of Option Holderthe Company, with full power of substitution in the premises. Dated: ____________________ X________________________ Signature Guaranteed _________________________ Social Security Number of Option Holder: ________________________________ If THE SIGNATURE TO THE ASSIGNMENT OR THE SUBSCRIPTION FORM MUST CORRESPOND TO THE NAME AS WRITTEN UPON THE FACE OF THIS WARRANT CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, AND MUST BE GUARANTEED BY A COMMERCIAL BANK OR TRUST COMPANY OR A MEMBER FIRM OF THE AMERICAN STOCK EXCHANGE, NEW YORK STOCK EXCHANGE, PACIFIC STOCK EXCHANGE OR MIDWEST STOCK EXCHANGE. AMENDMENT TO THE WARRANT AGREEMENT Amendment No. 1 to the certificate is Warrant Agreement (the "Warrant Agreement") dated March 19, 1998 between AccuMed International, Inc., a Delaware corporation (the "Company"), and Commonwealth Associates (the "Placement Agent"). Capitalized terms not otherwise defined herein shall have the respective meanings set forth in the Warrant Agreement. The parties hereto agree to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with amendments to the issuance terms of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderWarrant Agreement:

Appears in 1 contract

Samples: Warrant Agreement (Accumed International Inc)

NOTICE OF EXERCISE. ToTO: EMPYREAN BIOSCIENCE, INC. The undersigned, pursuant to the provisions set forth in the attached Warrant, hereby irrevocably elects to purchase (check applicable box): ___ ________ shares of the Common Stock covered by such Warrant; or ___ the maximum number of shares of Common Stock covered by such Warrant pursuant to the cashless exercise procedure set forth in Section 2. The undersigned herewith makes payment of the full purchase price for such shares at the price per share provided for in such Warrant, which is $___________. Such payment takes the form of (check applicable box or boxes): ___ $__________ in lawful money of the United States; and/or ___ the cancellation of such portion of the attached Warrant as is exercisable for a total of _______ shares of Common Stock (using a Fair Market Value of $_______ per share for purposes of this calculation); and/or ___ the cancellation of such number of shares of Common Stock as is necessary, in accordance with the formula set forth in Section 2.2 (b), to exercise this Warrant with respect to the maximum number of shares of Common Stock purchaseable pursuant to the cashless exercise procedure set forth in Section 2.2 (b). The undersigned requests that the certificates for such shares be issued in the name of, and delivered to ____________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed whose address is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number . The undersigned hereby confirms and acknowledges that the shares of Option Holder: ________________________________ If the certificate is Common Stock to be issued to person other than upon this exercise are being acquired solely for the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance account of the Common Stockundersigned and not as a nominee for any other party, if and for investment, and that the undersigned will not offer, sell or otherwise dispose of any such shares of Common Stock may except under circumstances that will not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with result in a view to, or for resale in connection with, a distribution of the shares within the meaning violation of the Securities Act of 1933 1933, as amended, or any applicable state securities laws. Dated: ---------------------- ------------------------------------------ (Signature must conform to name of Holder as specified on the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one face of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderWarrant) ------------------------------------------ (Address)

Appears in 1 contract

Samples: Empyrean Bioscience Inc

NOTICE OF EXERCISE. To: ISLET SCIENCES, INC. The undersigned ____________, pursuant to the provisions of the within Warrant, hereby elects to purchase ______________ shares of Common Stock of Islet Sciences, Inc., a Nevada corporation, covered by the within Warrant. The undersigned is an “accredited investor” as defined in Regulation D under the Securities Act of 1933, as amended. The undersigned intends that payment of the Warrant Price shall be made as (check one): Cash Exercise: _______ Cashless Exercise: _______ If the Holder has elected a Cash Exercise, the Holder shall pay the sum of $________ by certified or official bank check (or via wire transfer) to the Issuer in accordance with the terms of the Warrant. If the Holder has elected a Cashless Exercise, a certificate shall be issued to the Holder for the number of shares equal to the whole number portion of the product of the calculation set forth below, which is _________. The Issuer shall pay a cash adjustment in respect of the fractional portion of the product of the calculation set forth below in an amount equal to the product of the fractional portion of such product and the Per Share Market Value on the date of exercise, which product is: N/A. X = (A x B) - (A x C) Where: The total number of shares with respect to which this Warrant is being exercised: (“A”). The VWAP on the Trading Day immediately preceding the date of the Exercise Notice: (“B”). The Exercise Price in effect for the applicable Warrant Shares at the time of such exercise: $ (“A”) Dated: Signature: Address: ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder whose address is ________________________________________________________________ Telephone Number of Option Holder: . _______________________________________________________________ Social Security Number of Option Dated: ______________, Holder’s Signature: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person’s Address: ________________________________ (Name) ________________________________ (Address) ________________________________ _____________________________ Signature Guaranteed: ____ ________________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection NOTE: The signature to this Assignment Form must correspond with the issuance name as it appears on the face of the Common StockWarrant, if without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the Common Stock may not be immediately publicly soldforegoing Warrant. EXHIBIT B INVESTOR QUESTIONNAIRE ISLET SCIENCES, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view toINC. Confidential Investor Questionnaire To: Islet Sciences, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderInc.

Appears in 1 contract

Samples: Escrow Agreement (Islet Sciences, Inc)

NOTICE OF EXERCISE. ToTo Be Executed by the Holder in Order to Exercise the Series T Common Stock Purchase Warrant TO: __________________SolarWindow Technologies, Inc. 0000 Xxxx Xxxx Xxxx. Xxxxx 000-X Xxxxxxxxxx, XX 00000 Attention: President and Chief Executive Officer The undersigned Holder hereby elects to purchase ________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, Shares pursuant to the attached Series T Common Stock Option Agreement dated __________________. Number of Shares to Be PurchasedPurchase Warrant, and requests that certificates for securities be issued in the name of: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ __________________________________ __________________________________ (Telephone NumberPlease type or print name and address) __________________________________ (Social Security or Tax Identification Number) In connection with the issuance of the Common Stock, if the Common Stock may not and to be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view delivered to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am: ______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law______________. __________________________________________ (Please type or print name and address if different from above) If such number of Shares being purchased hereby shall not be all the Shares that may be purchased pursuant to the attached Warrant, a new Warrant for the balance of such Shares shall be registered in the name of, and delivered to, the Holder at the address set forth below. In full payment of the purchase price with respect to the Shares purchased and transfer taxes, if any, the undersigned hereby tenders payment of $__________ by check, money order or wire transfer payable in United States currency to the order of [________________]. HOLDER: By: Name: Title: Address: Dated: Annex B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) TO: SolarWindow Technologies, Inc. 0000 Xxxx Xxxx Xxxx. Xxxxx 000-X Xxxxxxxxxx, XX 00000 Attention: President and Chief Executive Officer FOR VALUE RECEIVED, ____________ shares of the foregoing Series T Common Stock Purchase Warrant of SolarWindow Technologies, Inc., and all rights evidenced thereby are hereby assigned to: whose address is: (Print Name) (Address) (City, State, Zip) Dated:___, 20______ Holder’s Signature: Holder’s Address: Signature Guaranteed: _________________ Signature NOTE: The signature to this Assignment Form must correspond with the name as it appears on the face of Option Holderthe Series T Common Stock Purchase Warrant, without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the foregoing Series T Common Stock Purchase Warrant.

Appears in 1 contract

Samples: SolarWindow Technologies, Inc.

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________The undersigned, _______________ Facsimile: (____) _____-______ Please be advised that I the Holder of the foregoing Warrant, hereby elect to exercise my option to purchase shares of ___________irrevocably elects, pursuant to Section 3 of the Warrant, to exercise purchase rights represented by such Warrant for, and to purchase thereunder, --------------- shares of the Common Stock Option Agreement dated __________________. Number of Shares Xxxxxxxx Petroleum Corporation (the "Company") to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible which such Warrant relates and herewith makes payment of withholding taxes $ ---------------------- therefor, as follows: $ in cash, ----------------------- $ by wire transfer to the Company, ----------------------- $ by certified check or money order, or ----------------------- $ by cancellation of accrued interest, ----------------------- first, and then outstanding principal under the Secured Notes, and requests that certificates for such shares (and any other documents we may requiresecurities or property deliverable upon such conversion including a revised warrant) be delivered to the undersigned at the address set forth below the signature of the undersigned. Dated: ------------------------------ Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number -------------------------------------------------- By: ----------------------------------------------- (Signature of Option HolderAuthorized Officer) Title: ________________________________ If ----------------------------------------------- Address: -------------------------------------------------- -------------------------------------------------- -------------------------------------------------- APPENDIX B NOTICE OF CONVERSION The undersigned, the certificate is Holder of the foregoing Warrant, hereby elects pursuant to be issued Section 7 of the Warrant, to person other than convert the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance rights to purchase -------- shares of the Common StockStock covered by such Warrant and herewith makes payment in full therefor by surrender of such Warrant, if and requests that certificates for the Common Stock may not appropriate number of shares (and any other securities or property deliverable upon such conversion including a revised warrant) be immediately publicly sold, I hereby represent to issued in the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution name of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”)undersigned and delivered to its address as set forth below. I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ ----------------------------- Name of Holder: --------------------------------------------------- By: ----------------------------------------------- (Signature of Option HolderAuthorized Officer) Title: ----------------------------------------------- Address: -------------------------------------------------- -------------------------------------------------- --------------------------------------------------

Appears in 1 contract

Samples: Goodrich Petroleum Corp

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: DRTATTOFF, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DRTATTOFF, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible _ and (2) encloses a cash payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ______________________$__________ Address representing the aggregate exercise price for such Units. The undersigned hereby represents and warrants to the Company that it is an “Accredited Investor” within the meaning of Option Holder Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), and is acquiring these securities for its own account and not with a view to, or for sale in connection with, any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the securities it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DRTATTOFF, LLC, in transactions not including any public offering and that under such laws, such securities may only be sold pursuant to an effective and current registration statement under the Securities Act or an exemption from the registration requirements of the Securities Act and any other applicable restrictions, in which event a legend or legends will be placed upon the certificate(s) representing the Units issuable under this Warrant denoting such restrictions. The undersigned understands and acknowledges that the Company will rely on the accuracy of these representations and warranties in issuing the securities underlying the Warrant. Date: ______________________________________________________________________ Telephone Number of Option HolderWarrant Holder Name: __________________________________________________________ Social Security Number of Option HolderTaxpayer Identification Number: ___________________________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personBy: ________________________________ (Name) __________________________________________ Printed Name: _________________________________________________________________ Title: _______________________________________________________________________ Address: ____________________________________________________________________ Note: The above signature should correspond exactly with the name on the face of this Warrant or with the name of assignee appearing in assignment form below. AND, if said number of Units shall be less than the total number of Units purchasable under the Warrant, a new Warrant is to be issued in the name of said undersigned for the balance remaining of the Units purchasable thereunder less any fraction of a Unit paid in cash and delivered to the address stated above. ASSIGNMENT FORM To be executed by the Warrant Holder In order to Assign Warrants FOR VALUE RECEIVED,____________________________________ hereby sells, assigns and transfers unto PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER (AddressPlease print or type name and address) ______________________ of the Warrants represented by this Warrant, and hereby irrevocably constitutes and appoints ________________________ Attorney to transfer this Warrant on the books of the Company, with full power of substitution in the premises. Dated:______________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Registered Holder)

Appears in 1 contract

Samples: Dr. Tattoff, Inc.

NOTICE OF EXERCISE. To: This Notice of Exercise shall constitute proper notice pursuant to Section 5 of that certain Stock Option Agreement (the “Agreement”) dated as of the ____ day of _____________, 2012, between the Company and the undersigned. The undersigned hereby elects to exercise Optionee’s option to purchase __________________ ___________________shares of the common stock of the Company at a price of $_______ __________________________ Attention _________per share, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares for aggregate consideration of _$__________, pursuant on the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 5 of the Agreement, accompanies this notice. The undersigned reconfirms the representations and warranties set out in the Agreement as of the date hereof. The Optionee hereby directs the Company to issue, register and deliver the Stock Option Agreement dated __________________. certificates representing the shares as follows: Registration Information: Delivery Instructions: Name to appear on certificates Name Address Address Telephone Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): DATED at _____________________________, the _______ Address day of Option Holder _____________________, ___________________________________________ Telephone Number . (Name of Option Holder: ________________________________ Social Security Number Optionee – Please type or print) (Signature and, if applicable, Office) (Address of Option Holder: ________________________________ If Optionee) (Address of Optionee) (Fax Number) EXHIBIT B NATIONAL INSTRUMENT 45-106 QUESTIONNAIRE REQUIRED FOR CANADIAN OPTIONEES ONLY All capitalized terms herein, unless otherwise defined, have the certificate is to be issued to person other than meanings ascribed thereto in the Option HolderAgreement. The Optionee covenants, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent represents and warrants to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderthat:

Appears in 1 contract

Samples: Stock Option Agreement (Titan Iron Ore Corp.)

NOTICE OF EXERCISE. ToCORUS PHARMA, INC. 0000 0xx Xxxxxx, Xxxxx 000 Xxxxxxx, XX 00000 Ladies and Gentlemen: This constitutes notice under my stock option that I elect to purchase the number of shares (the “Purchased Shares”) for the price set forth below. Type of option (check one): _____/ ISO ____/ Nonstatutory Option Date of Stock Option: __________________________ _Number of Purchased Shares: _________________________ _Certificates to be Issued in the Name of: _________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Exercise Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder _______________________________________Cash Payment Delivered Herewith: $_________________________ Telephone Number of Option Holder: _______Promissory Note delivered herewith (only applicable if approved by the Company): $_________________________ Social Security Number Fair Market Value of Option Holdershares of Stock delivered herewith: _______$_________________________ If By this exercise, the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ undersigned Optionee (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stockand Optionee’s spouse, if the Common Stock may not be immediately publicly sold, I hereby represent Optionee is married) agree(s) (i) to provide and/or execute and deliver to the Company that I am acquiring such additional documents as the Common Company may require pursuant to the terms of the Corus Pharma, Inc. 2001 Stock for my own account for investment and not with a view toPlan (the “Plan”), or for resale in connection withincluding, without limitation, a distribution stock purchase agreement in form and substance satisfactory to the Company, (ii) to provide for the payment by me to the Company (in the manner designated by me as permitted under the Plan and my option agreement) of my withholding obligation, if any, relating to the exercise of this option, and (iii) if this exercise relates to an incentive stock option (“ISO”), to notify the Company in writing prior to any disposition of any of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My Common Stock issued upon exercise of this option that occurs within two (2) years after the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state lawdate of grant of this option or within one (1) year after such shares of Common Stock are issued upon exercise of this option. ________________________________ Dated: _________________ Very truly yours, Signature of Option HolderOptionee Date Signature of Optionee’s Spouse Date

Appears in 1 contract

Samples: Stock Option Agreement (Gilead Sciences Inc)

NOTICE OF EXERCISE. To: __________This Notice of Exercise shall constitute proper notice pursuant to Section 0 of that certain Stock Option Agreement (the "Agreement") dated as of December 16, 2004, between Bulldog Technologies Inc. (the "Company") and the undersigned. The undersigned hereby elects to exercise Optionee's option to purchase ________________ shares of the common stock of the Company at a price of US$1.60 per share, for aggregate consideration of US$__________________________ __________________________ Attention _________, _______________ Facsimileon the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 0 of the Agreement, accompanies this notice. The Optionee hereby directs the Company to issue, register and deliver the certificates representing the shares as follows: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be PurchasedRegistration Information: Delivery Instructions: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________________ Name to appear on certificates Name ________________________________________ ________________________________________ Address Address ________________________________________ ________________________________________ ________________________________________ ________________________________________ Telephone Number DATED at ____________________________________, the ________ day of __________________, _______. ________________________________________ (Telephone NumberName of Optionee - Please type or print) ________________________________________ (Social Security Number) In connection with the issuance of the Common StockSignature and, if the Common Stock may not be immediately publicly soldapplicable, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I amOffice) ______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: (Address of Optionee) ________________________________________ Signature (City, State, and Zip Code of Option HolderOptionee) ________________________________________ (Fax Number) EXHIBIT B ACCREDITED INVESTOR QUESTIONNAIRE All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the Agreement. The Optionee covenants, represents and warrants to the Company that it satisfies one or more of the categories of "Accredited Investors", as defined by Regulation D promulgated under the 1933 Act, as indicated below: (Please initial in the space provide those categories, if any, of an "Accredited Investor" which the Optionee satisfies) ______ Category 1 An organization described in Section 501(c)(3) of the United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the specific purpose of acquiring the Units, with total assets in excess of US $5,000,000;

Appears in 1 contract

Samples: Option and Subscription Agreement (Bulldog Technologies Inc)

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NOTICE OF EXERCISE. ToTO: ICONIC BRANDS, INC. The undersigned hereby elects to purchase Warrant Shares of the Company pursuant to the terms of the attached Warrant (only if exercised in full), and tenders herewith payment of the exercise price in full, together with all applicable transfer taxes, if any. Payment shall take the form of lawful money of the United States. Please issue a certificate or certificates representing said Warrant Shares in the name of the undersigned or in such other name as is specified below: The Warrant Shares shall be delivered to the following DWAC Account Number or by physical delivery of a certificate to: Accredited Investor. The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended. [SIGNATURE OF HOLDER] Name of Investing Entity: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address Signature of Option Holder Authorized Signatory of investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ Telephone Number ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [ ] all of Option Holderor [ ] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to whose address is . Dated: _________________________________________ Social Security Number of Option Holder’s Signature: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person’s Address: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ Signature Guaranteed: ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 1 contract

Samples: Common Stock Purchase Warrant (Iconic Brands, Inc.)

NOTICE OF EXERCISE. ToTo Be Executed by the Holder in Order to Exercise the Series I Common Stock Purchase Warrant TO: __________________RenovaCare, Inc. 0000 Xxxx Xxxx Xxxx. Suite 107-A Scottsdale, AZ 85260 Attention: President and Chief Executive Officer The undersigned Holder hereby elects to purchase ________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, Shares pursuant to the attached Series I Common Stock Option Agreement dated __________________. Number of Shares to Be PurchasedPurchase Warrant, and requests that certificates for securities be issued in the name of: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ __________________________________ _________________________________ (Telephone NumberPlease type or print name and address) ____________________________________ (Social Security or Tax Identification Number) In connection with the issuance of the Common Stock, if the Common Stock may not and to be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view delivered to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am: ______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law______________. __________________________________________ (Please type or print name and address if different from above) If such number of Shares being purchased hereby shall not be all the Shares that may be purchased pursuant to the attached Warrant, a new Warrant for the balance of such Shares shall be registered in the name of, and delivered to, the Holder at the address set forth below. In full payment of the purchase price with respect to the Shares purchased and transfer taxes, if any, the undersigned hereby tenders payment of $__________ by check, money order or wire transfer payable in United States currency to the order of [________________]. HOLDER: By: Name: Title: Address: Dated: Annex B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) TO: RenovaCare, Inc. 0000 Xxxx Xxxx Xxxx. Suite 107-A Scottsdale, AZ 85260 Attention: President and Chief Executive Officer FOR VALUE RECEIVED, ____________ shares of the foregoing Series I Common Stock Purchase Warrant of RenovaCare, Inc. and all rights evidenced thereby are hereby assigned to: whose address is: (Print Name) (Address) (City, State, Zip) Dated:___, 20______ Holder’s Signature: Holder’s Address: Signature Guaranteed: _________________ Signature NOTE: The signature to this Assignment Form must correspond with the name as it appears on the face of Option Holderthe Series ICommon Stock Purchase Warrant, without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the foregoing Series ICommon Stock Purchase Warrant.

Appears in 1 contract

Samples: RenovaCare, Inc.

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on June 15, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to representing the aggregate exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I Unitss. The undersigned hereby represent represents and warrants to the Company that I am it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), and is acquiring the Common Stock these securities for my its own account for investment and not with a view to, or for resale sale in connection with, a any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares within it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that under such laws, such shares may only be sold pursuant to an effective and current registration statement under the meaning Securities Act or an exemption from the registration requirements of the Securities Act of 1933 (and any other applicable restrictions, in which event a legend or legends will be placed upon the “Securities Act”)certificate(s) representing the Units issuable under this Warrant denoting such restrictions. I am______ am not ______ [please initial one] an accredited investor for at least one of The undersigned understands and acknowledges that the reasons Company will rely on the attached Exhibit A. If accuracy of these representations and warranties in issuing the SEC has amended securities underlying the rule defining the definition Warrant. [warrant notice of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Datedsignature page] Date: _________________ Signature of Option HolderWarrant Holder Name: Taxpayer Identification Number: By: Printed Name: Title: Address:

Appears in 1 contract

Samples: Lifesciences Opportunities Inc

NOTICE OF EXERCISE. To: _5 G WIRELESS COMMUNICATIONS INC. The undersigned hereby elects to purchase _________________________ ____shares of Common Stock of 5 G WIRELESS COMMUNICATIONS, INC. ("Shares") pursuant to the terms of the attached Warrant Certificate, and (check the appropriate box): |_| tenders herewith payment for the purchase of ______________________ ____shares of Common Stock; and/or |_| elects to exercise Net Issue Exercise, as provided in Section 2(b) of the Warrant Agreement, for the purchase of ______________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock. In exercising the Warrant, pursuant to the undersigned hereby confirms and acknowledges that the shares of Common Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than upon conversion thereof are being acquired solely for the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance account of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment undersigned and not with as a view tonominee for any other party, or for resale investment, and that the undersigned will not offer, sell or otherwise dispose of any such shares of Common Stock except under circumstances that will not result in connection with, a distribution of the shares within the meaning violation of the Securities Act of 1933 (1933, as amended, or any applicable state securities laws. Please issue a certificate or certificates representing said shares of Common Stock in the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one name of the reasons on undersigned or in such other name(s) as is specified below: --------------------------------------- --------------------------------------- --------------------------------------- Please issue a new Warrant Certificate for the unexercised portion of the attached Exhibit A. If Warrant Certificate in the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise name of the Options shall be undersigned or in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Datedsuch other name(s) as is specified below: _________________ --------------------------------------- --------------------------------------- HOLDER: ---------------------------------- ------------------------------------ Signature of Option HolderHolder Date ---------------------------------- ------------------------------------ Printed Name of Holder Amount of Payment

Appears in 1 contract

Samples: Warrant Agreement (5 G Wireless Communications Inc)

NOTICE OF EXERCISE. To: ______________This Notice of Exercise shall constitute proper notice pursuant to Section 1.8 of that certain Stock Option Agreement (the "Agreement") dated as of March 14, 2005, between Bulldog Technologies Inc. (the "Company") and the undersigned. The undersigned hereby elects to exercise Optionee's option to purchase ____________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of _the common stock of the Company at a price of US$1.15 per share, for aggregate consideration of US$__________, pursuant on the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 1.8 of the Agreement, accompanies this notice. The Optionee hereby directs the Company to issue, register and deliver the Stock Option Agreement dated __________________. certificates representing the shares as follows: Registration Information: Delivery Instructions: Name to appear on certificates Name Address Address Telephone Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder DATED at ____________________________________, the ______ day of ___________________, _________ Telephone Number . (Name of Option Holder: ________________________________ Social Security Number Optionee – Please type or print) (Signature and, if applicable, Office) (Address of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option HolderOptionee) (City, please provide the following for such person: ________________________________ State, and Zip Code of Optionee) (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Fax Number) ________________________________ (Social Security Number) In connection with D/ljm/703938.1 EXHIBIT B ACCREDITED INVESTOR QUESTIONNAIRE All capitalized terms herein, unless otherwise defined, have the issuance of meanings ascribed thereto in the Common StockAgreement. The Optionee covenants, if the Common Stock may not be immediately publicly sold, I hereby represent represents and warrants to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, it satisfies one or for resale in connection with, a distribution more of the shares within the meaning categories of the Securities Act of 1933 (the Securities ActAccredited Investors). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions defined by Regulation D promulgated under the Securities Act and applicable state law. ________________________________ Dated1933 Act, as indicated below: _________________ Signature (Please initial in the space provide those categories, if any, of Option Holderan “Accredited Investor” which the Optionee satisfies)

Appears in 1 contract

Samples: Stock Option and Subscription Agreement (Bulldog Technologies Inc)

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, Stock if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 1 contract

Samples: Non Qualified Stock Option Agreement (Giga Tronics Inc)

NOTICE OF EXERCISE. To: _US DATAWORKS, INC. The undersigned hereby elects to purchase _________________________ ____shares of Common Stock of US DATAWORKS, INC. ("Shares") pursuant to the terms of the attached Warrant Certificate, and (check the appropriate box): [ ] tenders herewith payment for the purchase of ______________________ ____shares of Common Stock; and/or [ ] elects to exercise Net Issue Exercise, as provided in Section 2(b) of the Warrant Agreement, for the purchase of ______________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock. In exercising these Warrants, pursuant to the undersigned hereby confirms and acknowledges that the shares of Common Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than upon conversion thereof are being acquired solely for the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance account of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment undersigned and not with as a view tonominee for any other party, or for resale investment, and that the undersigned will not offer, sell or otherwise dispose of any such shares of Common Stock except under circumstances that will not result in connection with, a distribution of the shares within the meaning violation of the Securities Act of 1933 (1933, as amended, or any applicable state securities laws. Please issue a certificate or certificates representing said shares of Common Stock in the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one name of the reasons on undersigned or in such other name(s) as is specified below: -------------------------------------------- -------------------------------------------- -------------------------------------------- Please issue a new Warrant Certificate for the unexercised portion of the attached Exhibit A. If Warrant Certificate in the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise name of the Options shall be undersigned or in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Datedsuch other name(s) as is specified below: _________________ -------------------------------------------- -------------------------------------------- HOLDER: ---------------------------------- ---------------------------------- Signature of Option HolderHolder Date ---------------------------------- ---------------------------------- Printed Name of Holder Amount of Payment

Appears in 1 contract

Samples: Warrant Agreement (Us Dataworks Inc)

NOTICE OF EXERCISE. To: To Be Executed by the Registered Holder In Order to Exercise Warrants The undersigned Registered Holder hereby irrevocably elects to exercise ______________ Warrants represented by this Warrant, and to purchase the shares of Common Stock issuable upon the exercise of such Warrants, and requests that certificates for such shares of Common Stock shall be issued in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER [ ] ----------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- (please print or type name and address) and be delivered to ----------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- (please print or type name and address) and if such number of Warrants shall not be all the Warrants evidenced b this Warrant Certificate, that a new Warrant Certificate for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. Dated:_____________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____Signature of Registered Holder) _____-______ Please -------------------------------------- (Address) (Taxpayer Identification Number) -------------------------------------- Signature Guaranteed ASSIGNMENT FORM To be advised that I hereby elect executed by the Registered Holder In order to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ____________________________Assign Warrants FOR VALUE RECEIVED,____________________________________ Telephone Number of Option Holder: hereby sell, assigns and transfer unto PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER [ ] ----------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- (please print or type name and address) ______________________ of the Warrants represented by this Warrant, and hereby irrevocably constitutes and appoints ________________________ Social Security Number Attorney to transfer this Warrant on the books of Option Holder: ________________the Company, with full power of substitution in the premises. Dated:________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: X__________________________________ (NameSignature of Registered Holder) ________________________________ ----------------------------------- (AddressSignature Guaranteed) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common StockTHE SIGNATURE ON THE ASSIGNMENT OR THE PURCHASE FORM MUST CORRESPOND TO THE NAME AS WRITTEN UPON THE FACE OF THIS WARRANT CERTIFICATE IN EVERY PARTICULAR, if the Common Stock may not be immediately publicly soldWITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, I AND MUST BE GUARANTEED BY A COMMERCIAL BANK OR TRUST COMPANY OR A MEMBER FIRM OF THE AMERICAN STOCK EXCHANGE, NEW YORK STOCK EXCHANGE, PACIFIC STOCK EXCHANGE OR MIDWEST STOCK EXCHANGE. CERTIFICATION OF STATUS OF TRANSFEREE TO BE EXECUTED BY THE TRANSFEREE OF THIS WARRANT The undersigned transferee hereby represent certifies to the Company registered Holder and to TII Industries, Inc. that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares transferee is an "accredited investor" within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor1933, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderamended.

Appears in 1 contract

Samples: Tii Industries Inc

NOTICE OF EXERCISE. To: ______DIGITAL GENERATION SYSTEMS, INC. The undersigned hereby elects to purchase ____________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock of Digital Generation Systems, Inc., pursuant to the Stock Option Agreement dated __________________. Number terms of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible attached Warrant and payment of withholding taxes the Exercise Price per share required under such Warrant accompanies this notice. The undersigned hereby represents and warrants that the undersigned is acquiring such shares for its own account for investment purposes only, and not with a view to distribution of such shares or any other documents we may requirepart thereof. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ___________________________WARRANTHOLDER: By: _____________________________________ Telephone Number of Option HolderAddress: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________________ Date: ______________________ Name in which shares should be registered: __________________________________________ THIS WARRANT AND THE SECURITIES ISSUABLE UPON THE EXERCISE HEREOF HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933. THEY MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED, HYPOTHECATED, OR OTHERWISE TRANSFERRED EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 1933, OR AN OPINION OF COUNSEL SATISFACTORY TO THE COMPANY THAT REGISTRATION IS NOT REQUIRED UNDER SUCH ACT OR UNLESS SOLD PURSUANT TO RULE 144 UNDER SUCH ACT. WARRANT TO PURCHASE COMMON STOCK OF DIGITAL GENERATION SYSTEMS, INC. VOID AFTER DECEMBER 9, 2001 This Warrant is issued to Technology Crossover Ventures II, C.V., or its registered assigns (Telephone Number"Holder") ________________________________ by Digital Generation Systems, Inc., a California corporation (Social Security Numberthe "Company"), on December 9, 1998 (the "Warrant Issue Date"). This Warrant is issued pursuant to the terms of that certain Common Stock and Warrant Purchase Agreement dated as of the date hereof (the "Purchase Agreement") In in connection with the Company's issuance to the Holder of shares of the Common Stock, if the Company's Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”"Common Shares"). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder.

Appears in 1 contract

Samples: Technology Crossover Management Ii LLC

NOTICE OF EXERCISE. To: __________________To Be Executed by the Registered Holder in Order to Exercise Warrants The undersigned Registered Holder hereby irrevocably elects to exercise ________ __________________________ __________________________ Attention _________Warrants represented by this Warrant Certificate, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option and to purchase shares the securities issuable upon the exercise of ___________such Warrants, pursuant to and requests that certificates for such securities shall be issued in the Stock Option Agreement dated __________________. Number of Shares to Be Purchasedname of: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ [please print or type name and address] and be delivered to ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant Certificate for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated above. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. ______________________________________ (Telephone NumberName of NASD Member) Dated:_________________________ X__________________________ ___________________________ ___________________________ Address ______________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I amTaxpayer Identification Number ______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderGuaranteed THE SIGNATURE TO THE ASSIGNMENT OR THE EXERCISE NOTICE MUST CORRESPOND TO THE NAME AS WRITTEN UPON THE FACE OF THIS WARRANT CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, AND MUST BE GUARANTEED BY A COMMERCIAL BANK OR TRUST COMPANY OR A MEMBER FIRM OF THE AMERICAN STOCK EXCHANGE, NEW YORK STOCK EXCHANGE, PACIFIC STOCK EXCHANGE OR MIDWEST STOCK EXCHANGE.

Appears in 1 contract

Samples: Warrant Agreement (Accumed International Inc)

NOTICE OF EXERCISE. (Complete and sign only upon exercise of the Common Stock Purchase Warrant in whole or in part.) To: _________________EVO Transportation & Energy Services, Inc. The undersigned, the holder of the attached Common Stock Purchase Warrant to which this Notice of Exercise applies (the “Warrant”), hereby irrevocably elects to exercise pursuant to Section 2.1 of the Warrant and to purchase _________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________Common Stock, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________from EVO Transportation & Energy Services, 20__. Please contact me as soon as possible to discuss the possible Inc. and herewith makes payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ____$____________________________ Address of Option Holder therefor in cash or by certified or official bank check. The undersigned hereby requests that such securities be issued in the name(s) and delivered to the address(es) as follows: Name: ________________________________________________________________________ Telephone Number of Option HolderAddress: ______________________________________________________________________ Social Security Number of Option HolderNumber: __________________________________________________________ Deliver to: _____________________________________________________________________ Address: ______________________________________________________________________ If the certificate foregoing evidences an exercise of the Warrant to purchase fewer than all of the shares of Common Stock to which the undersigned is to be issued to person other than the Option Holderentitled under such warrant, please provide issue a new warrant, of like tenor, relating to the following for remaining portion of the securities issuable upon exercise of such personwarrant in the name(s), and deliver the same to the address(es), as follows: Name: ________________________________ (Name) _________________________________________ (Address) : ______________________________________________________________________ Dated: ________________________________________________________________________ ________________________________ ______________________________________________ (Telephone NumberName of Warrant Holder) ________________________________ (Social Security Number) In connection with the issuance or Taxpayer Identification Number of the Common StockWarrant Holder, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”applicable). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holder

Appears in 1 contract

Samples: EVO Transportation & Energy Services, Inc.

NOTICE OF EXERCISE. To: __________________________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $_______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ___________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderHolder Exhibit A

Appears in 1 contract

Samples: Employee Non Qualified Stock Option Agreement (Aspen Group, Inc.)

NOTICE OF EXERCISE. To: ___________________Nuvel Holdings Inc. Attention: The undersigned hereby elects to purchase, pursuant to the provisions of the Warrant, as follows: _______ ____________________ shares of Common Stock pursuant to the terms of the Warrant, and tenders herewith payment in cash of the Exercise Price for the Warrant Shares in full, together with all applicable transfer taxes, if any. _______ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect Cashless Exercise with respect to exercise my option to purchase the Net Number of shares of ___________Common Stock. The undersigned hereby represents and warrants that the representations and warranties in Section 2 of the Subscription Agreement, pursuant to are true and correct as of the Stock Option Agreement dated __________________date hereof. Number of Shares to Be PurchasedHOLDER: _______________ Multiplied byIf an individual: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderBy: ________________________________ Social Security Number of Option HolderName: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personAddress: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ If an entity: By: ________________________________ (Telephone Number) Name: ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. Title: ________________________________ Address: ________________________________ ________________________________ Dated as of: __________ _____, 201_ Name in which shares should be registered: __________________________________________ Address at which shares should be registered: __________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to _________________________________ whose address is _____________________________________________________________________________. Dated: ______________, Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________ NOTE: The signature to this Assignment Form must correspond with the name as it appears on the face of Option Holderthe Warrant, without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the foregoing Warrant.

Appears in 1 contract

Samples: Nuvel Holdings, Inc.

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on June 15, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to representing the aggregate exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I Unitss. The undersigned hereby represent represents and warrants to the Company that I am it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), and is acquiring the Common Stock these securities for my its own account for investment and not with a view to, or for resale sale in connection with, a any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares within it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that under such laws, such shares may only be sold pursuant to an effective and current registration statement under the meaning Securities Act or an exemption from the registration requirements of the Securities Act of 1933 (and any other applicable restrictions, in which event a legend or legends will be placed upon the “Securities Act”)certificate(s) representing the Units issuable under this Warrant denoting such restrictions. I am______ am not ______ [please initial one] an accredited investor for at least one of The undersigned understands and acknowledges that the reasons Company will rely on the attached Exhibit A. If accuracy of these representations and warranties in issuing the SEC has amended securities underlying the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option HolderWarrant.

Appears in 1 contract

Samples: Lifesciences Opportunities Inc

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on July 20, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to representing the aggregate exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I Unitss. The undersigned hereby represent represents and warrants to the Company that I am it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), and is acquiring the Common Stock these securities for my its own account for investment and not with a view to, or for resale sale in connection with, a any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares within it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that under such laws, such shares may only be sold pursuant to an effective and current registration statement under the meaning Securities Act or an exemption from the registration requirements of the Securities Act of 1933 (and any other applicable restrictions, in which event a legend or legends will be placed upon the “Securities Act”)certificate(s) representing the Units issuable under this Warrant denoting such restrictions. I am______ am not ______ [please initial one] an accredited investor for at least one of The undersigned understands and acknowledges that the reasons Company will rely on the attached Exhibit A. If accuracy of these representations and warranties in issuing the SEC has amended securities underlying the rule defining the definition Warrant. [warrant notice of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Datedsignature page] Date: _________________ Signature of Option HolderWarrant Holder Name: Taxpayer Identification Number: By: Printed Name: Title: Address:

Appears in 1 contract

Samples: Lifesciences Opportunities Inc

NOTICE OF EXERCISE. To: _____________MR3 SYSTEMS, INC. The undersigned hereby elects to purchase _____________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of ____________ Stock (the “Shares”) of MR3 Systems, Inc., a Delaware corporation (the “Company”) pursuant to the terms of the attached Warrant, and tenders herewith payment of the purchase price pursuant to the terms of the Warrant. Attached as Exhibit A is an investment representation letter addressed to the Company and executed by the undersigned as required by Section 10 of the Warrant. Please issue certificates representing the Common Stock Option Agreement dated __________________purchased hereunder in the names and in the denominations indicated on Exhibit A attached hereto. Number Please issue a new Warrant for the unexercised portion of Shares to Be Purchasedthe attached Warrant, if any, in the name of the undersigned. Dated: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________________ Name:_________________________________________ (Telephone Number) Title:__________________________________________ (Social Security Number) In connection with the issuance of the Common StockEXHIBIT B STOCK PURCHASE AND LOAN OPTION AGREEMENT NET ISSUANCE ELECTION NOTICE To: MR3 SYSTEMS, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”)INC. I amDate:_____________ am not The undersigned hereby elects under Section 2 of the attached Warrant to surrender the right to purchase ___________ [please initial one] an accredited investor shares of ___________ Stock (the “Shares”) pursuant to the attached Warrant. The Certificate(s) for at least one the Shares issuable upon such net issuance election shall be issued in the name of the reasons undersigned or as otherwise indicated below. Attached as Exhibit A is an investment representation letter addressed to the Company and executed by the undersigned as required by Section 12 of the Warrant. Please issue certificates representing the Shares purchased hereunder in the names and in the denominations indicated on Exhibit A attached hereto. Please issue a new Warrant for the unexercised portion of the attached Exhibit A. If Warrant, if any, in the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise name of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state lawundersigned. ___________________________ Signature ______ Dated: ______________________ Signature Name for Registration ___________________________ Mailing Address EXHIBIT B STOCK PURCHASE AND LOAN OPTION AGREEMENT EXHIBIT A-1 To: MR3 SYSTEMS, INC. In connection with the purchase by the undersigned of Option Holder_________ shares of Common Stock (the “Shares”) of MR3 Systems, Inc., a Delaware corporation (the “Company”), upon exercise of that certain Warrant dated as of _______, 2005, the undersigned hereby represents and warrants as follows: The Shares to be received by the undersigned upon exercise of the Warrant are being acquired for its own account, not as a nominee or agent, and not with a view to resale or distribution of any part thereof, and the undersigned has no present intention of selling, granting any participation in, or otherwise distributing the same. The undersigned further represents that it does not have any contract, undertaking, agreement or arrangement with any person to sell, transfer or grant participation to such person or to any third person, with respect to the Shares. The undersigned believes it has received all the information it considers necessary or appropriate for deciding whether to purchase the Shares. The undersigned understands that the Shares are characterized as “restricted securities” under the federal securities laws inasmuch as they are being acquired from the Company in transactions not involving a public offering and that under such laws and applicable regulations such securities may be resold without registration under the Securities Act of 1933, as amended (the “Act”), only in certain limited circumstances. In this connection, the undersigned represents that it is familiar with SEC Rule 144, as presently in effect, and understands the resale limitations imposed thereby and by the Act. Without in any way limiting the representations set forth above, the undersigned agrees not to make any disposition of all or any portion of the Shares unless and until: There is then in effect a registration statement under the Act covering such proposed disposition and such disposition is made in accordance with such registration statement; or

Appears in 1 contract

Samples: Stock Purchase and Loan Option Agreement (Mr3 Systems Inc)

NOTICE OF EXERCISE. ToTo Be Executed by the Warrant Holder In Order to Exercise Warrants TO: Dr. Xxxxxxx, LLC The undersigned hereby: (1) irrevocably subscribes for and offers to purchase _______ Units (“Units”), of DrTattoff, LLC, pursuant to Warrant No. ___ heretofore issued to ___________________ ________________on July 20, 2007 and (2) encloses a cash payment of $__________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to representing the aggregate exercise my option to purchase shares of ___________, pursuant to the Stock Option Agreement dated __________________. Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I Unitss. The undersigned hereby represent represents and warrants to the Company that I am it is an “Accredited Investor” within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933, as amended (the “Securities Act”), and is acquiring the Common Stock these securities for my its own account for investment and not with a view to, or for resale sale in connection with, a any distribution thereof, nor with any present intention of distributing or selling the same. The undersigned further represents that it does not have any contract, agreement, understanding or arrangement with any person to sell, transfer or grant the Units issuable under this Warrant. The undersigned understands that the shares within it will be receiving are “restricted securities” under Federal securities laws inasmuch as they are being acquired from DrTattoff, LLC, in transactions not including any public offering and that under such laws, such shares may only be sold pursuant to an effective and current registration statement under the meaning Securities Act or an exemption from the registration requirements of the Securities Act of 1933 (and any other applicable restrictions, in which event a legend or legends will be placed upon the “Securities Act”)certificate(s) representing the Units issuable under this Warrant denoting such restrictions. I am______ am not ______ [please initial one] an accredited investor for at least one of The undersigned understands and acknowledges that the reasons Company will rely on the attached accuracy of these representations and warranties in issuing the securities underlying the Warrant. Exhibit A. If the SEC has amended the rule defining the definition 10.18 [warrant notice of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Datedsignature page] Date: _________________ Signature of Option HolderWarrant Holder Name: Taxpayer Identification Number: By: Printed Name: Title: Address:

Appears in 1 contract

Samples: Lifesciences Opportunities Inc

NOTICE OF EXERCISE. To: This Notice of Exercise shall constitute proper notice pursuant to Section 5 of that certain Stock Option Agreement (the “Agreement”) dated as of the ____ day of _____________, 2011, between the Company and the undersigned. The undersigned hereby elects to exercise Optionee’s option to purchase __________________ ___________________shares of the common stock of the Company at a price of $_______ __________________________ Attention _________per share, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares for aggregate consideration of _$__________, pursuant on the terms and conditions set forth in the Agreement and the Plan. Such aggregate consideration, in the form specified in Section 5 of the Agreement, accompanies this notice. The undersigned reconfirms the representations and warranties set out in the Agreement as of the date hereof. The Optionee hereby directs the Company to issue, register and deliver the Stock Option Agreement dated __________________. certificates representing the shares as follows: Registration Information: Delivery Instructions: Name to appear on certificates Name Address Address Telephone Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): DATED at _____________________________, the _______ Address day of Option Holder _____________________, ___________________________________________ Telephone Number . (Name of Option Holder: ________________________________ Social Security Number Optionee – Please type or print) (Signature and, if applicable, Office) (Address of Option Holder: ________________________________ If Optionee) (Address of Optionee) (Fax Number) EXHIBIT B NATIONAL INSTRUMENT 45-106 QUESTIONNAIRE REQUIRED FOR CANADIAN OPTIONEES ONLY All capitalized terms herein, unless otherwise defined, have the certificate is to be issued to person other than meanings ascribed thereto in the Option HolderAgreement. The Optionee covenants, please provide the following for such person: ________________________________ (Name) ________________________________ (Address) ________________________________ ________________________________ ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent represents and warrants to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: _________________ Signature of Option Holderthat:

Appears in 1 contract

Samples: Stock Option Agreement (Titan Iron Ore Corp.)

NOTICE OF EXERCISE. To: ___________ABTECH HOLDINGS, INC. The undersigned hereby irrevocably exercises the right to purchase _______________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of _Common Stock of AbTech Holdings Inc., a Nevada corporation, evidenced by the attached Warrant, and tenders herewith payment of the aggregate Exercise Price with respect to such shares in full, in the amount of $__________, in cash, by certified or official bank check or by wire transfer for the account of the Company. The undersigned requests that stock certificates for such Warrant Shares be issued, and a Warrant representing any unexercised portion hereof be issued, pursuant to this Warrant, in the Stock Option Agreement dated __________________. Number name of Shares the registered Warrant Holder and delivered to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method undersigned at the address set forth below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option Holder: ________________________________ Social Security Number of Option Holder: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such person: ________________________________ (Name) ___________________________________ (Signature) ___________________________________ (Address) ______________________________ Signature Date:__________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to_______________________________________________________________________ whose address is ________________________________ (Telephone Number) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am______ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: ______________, Holder’s Signature: _____________________________ Holder’s Address: _____________________________ Signature Guaranteed: ___________________________________________ NOTE: The signature to this Assignment Form must correspond with the name as it appears on the face of Option Holderthe Warrant, without alteration or enlargement or any change whatsoever, and must be guaranteed by a bank or trust company. Officers of corporations and those acting in a fiduciary or other representative capacity should file proper evidence of authority to assign the foregoing Warrant. APRIL 13, 2015 CREDIT AGREEMENT – EXHIBIT C INVESTOR QUESTIONNAIRE ABTECH HOLDINGS, INC. Confidential Investor Questionnaire To: AbTech Holdings, Inc.

Appears in 1 contract

Samples: Credit Agreement (Abtech Holdings, Inc.)

NOTICE OF EXERCISE. To: ________________Xxxxxx Xxxxxxx Living Omnimedia, Inc. Attn: Administrator of the Omnibus Stock and Option Compensation Plan Subject: Notice of Intention to Exercise Stock Option This Notice of Exercise constitutes official notice that the undersigned intends to exercise Optionee's option to purchase __________ __________________________ __________________________ Attention _________, _______________ Facsimile: (____) _____-______ Please be advised that I hereby elect to exercise my option to purchase shares of Xxxxxx Xxxxxxx Living Omnimedia, Inc. Common Stock, under and pursuant to the Company's Omnibus Stock and Option Compensation Plan (the “Plan”) and the Notice of Stock Option Grant and Stock Option Agreement (the “Agreement”) dated ___________, pursuant to the Stock Option Agreement dated __________________. as follows: Number of Shares to Be Purchased: _______________ Multiplied by: Purchase Price Per Share $______________ Total Purchase Price $_______________ Please check the payment method below: ____ Enclosed is a check for the total purchase price above. ____ Wire transfer sent on _____________, 20__. Please contact me as soon as possible to discuss the possible payment of withholding taxes and any other documents we may require. Name of Option Holder (Please Print): ________________________________ Address of Option Holder ________________________________________________________________ Telephone Number of Option HolderShares: ________________________________ Social Security Number of Option HolderExercise Price per Share: ________________________________ If the certificate is to be issued to person other than the Option Holder, please provide the following for such personTotal Exercise Price: ________________________________ (Name) Method of Payment of Exercise Price: ________________________________ The shares should be registered in the name (Addresss) of: __________________________ and __________________________.1 By signing below, I hereby agree to be bound by all of the terms and conditions set forth in the Plan and the Agreement. If applicable, proof of my right to purchase the shares pursuant to the Plan and the Agreement is enclosed.2 Dated: ________________________________ ________________________________ ________________________________ (Telephone NumberSignature) (Signature)3 ________________________________ ________________________________ (Please Print Name) (Please Print Name) ________________________________ (Social Security Number) In connection with the issuance of the Common Stock, if the Common Stock may not be immediately publicly sold, I hereby represent to the Company that I am acquiring the Common Stock for my own account for investment and not with a view to, or for resale in connection with, a distribution of the shares within the meaning of the Securities Act of 1933 (the “Securities Act”). I am_____________________________ am not ______ [please initial one] an accredited investor for at least one of the reasons on the attached Exhibit A. If the SEC has amended the rule defining the definition of accredited investor, the new provisions shall be applicable. I acknowledge that as a condition to exercise the Options, the Company may request updated information regarding the Holder’s status as an accredited investor. My exercise of the Options shall be in compliance with the applicable exemptions under the Securities Act and applicable state law. ________________________________ Dated: ______________________________ Signature (Full Address) (Full Address) ________________________________ 1 If more than one name is listed, please specify whether the owners will hold the shares as community property or as joint tenants with the right of survivorship. 2 Applicable if someone other than the Optionee (e.g., a death beneficiary) is exercising the stock option. 3 Each person in whose name shares are to be registered must sign this Notice of Exercise. EXHIBIT B XXXXXX XXXXXXX LIVING OMNIMEDIA, INC. OMNIBUS STOCK AND OPTION COMPENSATION PLAN RESTRICTED STOCK UNIT AGREEMENT This Restricted Stock Unit Agreement (the “Agreement”) is made and entered into as of October 28, 2013 by and between Xxxxxx Xxxxxxx Living Omnimedia, Inc., a Delaware corporation (the “Company”), and Xxxxxx Xxxxxx pursuant to the Xxxxxx Xxxxxxx Living Omnimedia, Inc. Omnibus Stock and Option HolderCompensation Plan (the “Plan”). To the extent any capitalized terms used in this Agreement are not defined, they shall have the meaning ascribed to them in the Plan, which is attached to, and made a part of, this Agreement. In the event of a conflict between the terms and provisions of the Plan and the terms and provisions of this Agreement, the Plan terms and provisions shall prevail. In consideration of the mutual agreements herein contained and intending to be legally bound hereby, the parties agree as follows:

Appears in 1 contract

Samples: Restricted Stock Unit Agreement (Martha Stewart Living Omnimedia Inc)

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