Name of Purchaser. SIGNATURE OF AUTHORIZED SIGNATORY OF PURCHASER: ________________________________ Name of Authorized Signatory: __________________________________________________ Title of Authorized Signatory: _________________________________________________ Email Address of Purchaser:_____________________________________________________ Address for Notice of Purchaser: Address for Delivery of Securities for Purchaser (if not same as above):
Name of Purchaser. Dated: By: Name: Title: Aggregate principal amount of: Purchase Money Notes due [February 25, 2012]: $ Purchase Money Notes due [February 25, 2013]: $ Purchase Money Notes due [February 25, 2014]: $ Taxpayer identification number: Address for notices: Wire transfer information for payments: Bank: Address: Bank ABA#: Account #: Telephone: FAO Facsimile: Attention: Attention: Registered Name: Delivery Instructions: This certificate and the statements contained herein are made for your benefit. [INSERT NAME OF HOLDER] By: Name: Title: Dated: , EXHIBIT D FORM OF DTC NOTICE TO INVESTORS The Depository Trust Company IMPORTANT NOTICE DATE: [ ] TO: ALL PARTICIPANTS FROM: Multibank 2009-1 CML-ADC Venture, LLC (the “Company”) Re.: Purchase Money Note due [February 25, 2012] (CUSIP No. [ ]); Purchase Money Note due [February 25, 2013] (CUSIP No. [ ]); Purchase Money Note due [February 25, 2014] (CUSIP No. [ ]); (collectively, the “Notes”) The Company referred to above is putting Participants on notice that they are required to follow these purchase and transfer restrictions with regard to the above-referenced Notes. In order to qualify for the exemption provided by Section 3(c)(7) under the Investment Company Act of 1940, as amended (the “Investment Company Act”), and the exemption provided by Rule 144A under the Securities Act of 1933, as amended (the “Securities Act”), offers, sales and resales of the above-referenced Notes within the United States or to persons that are U.S. Persons as defined in Regulation S under the Securities Act (“U.S. Persons”) or U.S. residents within the meaning of the Investment Company Act (“U.S. Residents”) may only be made in minimum denominations of U.S.$500,000 and integral multiples of U.S.$1,000 in excess thereof to “qualified institutional buyers” (“QIBs”) within the meaning of Rule 144A that are also “qualified purchasers” (“QPs”) within the meaning of Section 2(a)(51)(A) of the Investment Company Act. Each purchaser of Notes (I) represents to and agrees with the Company that (A)(i) the purchaser is a QIB that is a QP (a “QIB/QP”); (ii) the purchaser is not a broker-dealer that owns and invests on a discretionary basis less than U.S.$25 million in securities of unaffiliated issuers; (iii) the purchaser is not a pension, profit sharing or other retirement trust fund or plan in which the partners, beneficiaries or participants, as applicable, may designate the particular investments to be made, and in a transaction that may be effe...
Name of Purchaser. Dated: By: Name: Title: Outstanding principal amount of [Class [A] [B] [C] [D] [E]] [[Senior][Junior] Subordinated] Notes: $__________
Examples of Name of Purchaser in a sentence
Signature of Authorized Purchaser Print Name Here Title Date Streamlined Sales and Use Tax Agreement Certificate of Exemption Multistate Supplemental Name of Purchaser: STATE Reason for Exemption Identification Number (If Required) AR* GA IA IN KS KY MI MN NC ND NE NJ NV OH OK RI SD TN* UT VT WA WI WV WY *SSUTA Direct Mail provisions are not in effect for Arkansas and Tennessee.
Signature of Authorized Purchaser Print Name Here Title Date 21999 (8/27/09) Streamlined Sales and Use Tax Agreement Certificate of Exemption Multi-state Supplemental Name of Purchaser STATE Reason for Exemption Identification Number (If Required) AR IA IN KS KY MI MN NC ND NE NJ NV OH OK RI SD TN UT VT WA WI WV WY SSUTA Direct Mail provisions are not in effect for Tennessee.
Signature of Authorized Purchaser Print Name Here Title Date Streamlined Sales and Use Tax Agreement Certificate of Exemption SSTGB Form F0003 Exemption Certificate (2/22/08) Multi-state Supplemental Name of Purchaser STATE Reason for Exemption Identification Number (If Required) AR IA IN KS KY MI MN NC ND NE NJ NV OH OK RI SD TN UT VT WA WV WY SSUTA Direct Mail provisions are not in effect for Tennessee.
If No Tax ID Number,Enter One of the Following: FEIN Driver’s License Number/State Issued ID Number State of Issue Number Foreign Diplomat Number Name of Purchaser Business Address City State Zip Code Purchaser’s Tax ID Number State of Issue Country of Issue Name of Seller From Whom You Are Purchasing, Leasing, or Renting Seller’s Address City State Zip Code Type of Business.
Signature Name Address Performance Security Bank Guarantee (unconditional) To : Tamilnadu Medical Services Corporation Limited (Name of Purchaser) Xx.000, Xxxxxxxx Xxxx, Xxxxxx, Xxxxxxx – 600 008.
More Definitions of Name of Purchaser
Name of Purchaser. Dated: --------------------------- ------------------------ By: ------------------------------ Name: Title: Aggregate principal amount of: Series [ ] Notes: $ ------------------- Taxpayer identification number: --------------------- Address for notices: Wire transfer information for payments: Bank: ---------------------------------------- Address: Bank ABA#: -------------------------------- Account #: -------------------------------- Telephone: -------------------------------- Facsimile: -------------------------------- EXHIBIT B TO ARG II BASE INDENTURE FORM OF CLEARING SYSTEM CERTIFICATE ARG Funding Corp. II 7700 France Avenue South Minneapolis, MN 55435 Attn: Jason Smith Assex Xxxxxx Xxxxxxxxxx 0 Xxxx Xxxxx - 00xx Xxxxx New Yorx, XX 00000 Attn: John Bobko Xxxxxxxxx xx xxxxxx xxxx xx xxx Xmended xxx Xxxxxxed Base Indenture dated as of [ ], 2002 (the "BASE INDENTURE") between ARG II, as Issuer, and The Bank of New York, as Trustee. Capitalized terms used but not defined herein shall have the meanings given to them in the Base Indenture. This is to certify that, based solely on certificates we have received in writing, by tested telex or by electronic transmissions from noteholders appearing in our records as persons being entitled to a portion of the original principal amount of the Series 2002-1 Notes, Class A-_ (the "NOTES") equal to, as of the date hereof, U.S.$_________ (our "NOTEHOLDERS"), certificates with respect to such portion, substantially to the effect set forth in Exhibit C to the Base Indenture. We further certify (i) that we are not making available herewith for exchange any portion of the Temporary Global Note excepted in such certificates and (ii) that as of the date hereof we have not received any notification from any of our Noteholders to the effect that the statements made by such Group III Noteholder with respect to any portion of the part submitted herewith for exchange are no longer true and cannot be relied upon as at the date hereof. We understand that this certification is required in connection with certain securities laws of the United States. In connection therewith, if administrative or legal proceedings are commenced or threatened in connection with which this certificate is or would be relevant, we irrevocably authorized you to produce this certification to any interested party in such proceedings. Dated: __________, 200_(1) Yours faithfully, EUROCLEAR BANK S.A./N.V., as operator of the Euroclear System or CLEARSTREAM BANK...
Name of Purchaser. Dated: By: Name: Title: Aggregate principal amount of: 26 Insert as appropriate Purchase Money Notes due [February 25, 2012]: $ Purchase Money Notes due [February 25, 2013]: $ Purchase Money Notes due [February 25, 2014]: $ EXHIBIT C-5 FORM OF CERTIFICATE FOR TRANSFER OR EXCHANGE OF GLOBAL NOTE TO CERTIFICATED NOTE Multibank 2009-1 CML-ADC Venture, LLC c/o Wells Fargo Bank, N.A., as Paying Agent 0xx Xxxxxx & Xxxxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 Attn: Corporate Trust Services Transfer Agent Department Re: Purchase Money Notes due [February 25, 2012][February 25, 2013][February 25, 2014]27 Ladies and Gentlemen:
Name of Purchaser. Instruction: Please sign but do not fill in any other blanks. The purpose of this assignment is to enable the Company to exercise its repurchase rights as set forth in the Agreement without requiring additional signatures on the part of the Stockholder. EXHIBIT A ASSIGNMENT SEPARATE FROM CERTIFICATE FOR VALUE RECEIVED, , hereby sells, assigns and transfers unto shares of the Common Stock of AcelRx Pharmaceuticals, Inc., a Delaware corporation (the “Company”), standing in the undersigned’s name on the books of said Company represented by Certificate No. herewith, and does hereby irrevocably constitute and appoint attorney to transfer the said stock on the books of the said Company with full power of substitution in the premises. Dated:
Name of Purchaser. Instruction: Please sign but do not fill in any other blanks. The purpose of this assignment is to enable the Company to exercise its repurchase rights as set forth in the Agreement without requiring additional signatures on the part of the Stockholder. EXHIBIT B JOINT ESCROW INSTRUCTIONS August 15, 2006 DLA Xxxxx Xxxxxxx Xxxx Xxxx US LLP 000 Xxxxxxxx Xxxxxx, Suite 800 San Francisco, CA 94107 Ladies and Gentlemen: As Escrow Agent for both AcelRx Pharmaceuticals, Inc., a Delaware corporation (“Company”), and the undersigned purchaser of Stock (the “Stock”) of the Company (“Purchaser”), you are hereby authorized and directed to hold the documents delivered to you pursuant to the terms of that certain Common Stock Purchase Agreement (“Agreement”), dated as of the date hereof, to which a copy of these Joint Escrow Instructions is attached as Exhibit B, in accordance with the following instructions:
Name of Purchaser. Del Mar Master Fund, Ltd. Signature of Authorized Signatory of Purchaser: /s/ Xxxxx X. Xxxxxxxx Name of Authorized Signatory: Xxxxx X. Xxxxxxxx Title of Authorized Signatory: Managing Member Email Address of Authorized Signatory: Facsimile Number of Authorized Signatory: Address for Notice to Purchaser: Address for Delivery of Securities to Purchaser (if not same as address for notice): Subscription Amount: $2,420,000 Shares: 1,512,500 EIN Number: [Provided Separately] [PURCHASER SIGNATURE PAGES CONTINUE] DISCLOSURE SCHEDULES The Company Disclosure Schedule (the “Disclosure Schedule”) is being delivered in connection with that certain Securities Purchase Agreement (the “Agreement”) dated as of December 24, 2013, by and among DS Healthcare Group, Inc. (the “Company”) and the Purchasers identified on the signature page to the Agreement. Capitalized terms used, but not otherwise defined, in this Disclosure Schedule shall have the meanings ascribed to them in the Agreement. The Disclosure Schedule is qualified in its entirety by reference to the specific provisions of the Agreement. In addition, information set forth in this Disclosure Schedule modifies, supplements, qualifies or limits the representations and warranties made by the Company in the Agreement. The Disclosure Schedule is arranged in sections corresponding to the sections contained in the Agreement, but the disclosure of an item in one section of this Disclosure Schedule shall be deemed adequately disclosed in each other section of this Disclosure Schedule. The headings contained in this Disclosure Schedule are included for convenience only, and shall not be deemed to constitute a part of this Disclosure Schedule or a part of the Agreement. The specification of any dollar amount in this Disclosure Schedule is not intended and shall not be deemed to be an admission or acknowledgment of the materiality of such amounts or items, nor shall the same be used in any dispute or controversy between the parties to determine whether any obligation, item or matter (whether or not described herein or included in any schedule) is or is not material for purposes of the Agreement. Schedule 3.1(a) Subsidiaries · DS Laboratories Inc. · Sigma Development and Holding Co., Inc. · Polaris Labs, Inc. · Nutra Origin, Inc. · Velocity Storage and Packaging, LLC (Variable Interest Entity – the Company’s variable interest relates to a financing arrangement whereby all operational expenses, including labor costs, facility cos...
Name of Purchaser. Date: Signature: Telephone: Address: DOB: Hearing Aid Specialist: Xxxxx Xxxxx-Xxxxxxxx, H.A.S. ACA Signature: License Number: HA4026 If the hearing aids are returned after the 30 day trial period the patient may be liable for fees related to the fittings and adjustments, restocking fee, and appointments provided by the hearing aid specialist. If you wish to inquire about these fees, please contact the office at 000-000-0000.
Name of Purchaser. By: ___________________________ Name: Title: Aggregate Purchase Price (Subscription Amount): $ ___________________ Number of Shares to be Acquired: Underlying Shares Subject to Warrant: (25% of the number of Shares to be acquired) Tax ID No.: ____________________ Address for Notice: _______________________________ _______________________________ _______________________________ Telephone No.: ________________________ Facsimile No.: _________________________ E-mail Address: ________________________ Attention: ____________________________ Delivery Instructions: (if different than above) c/o ________________________ Street: ______________________ City/State/Zip: ________________ Attention: ___________________ Telephone No.: ______________ EXHIBITS: