SUBSCRIPTION FORM. 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 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 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.
SUBSCRIPTION FORM. To 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 Common Stock issuable upon the exercise of such Warrants, and requests that Certificates for such shares shall be issued in the name of (PLEASE TYPE OR PRINT NAME AND ADDRESS) (SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER) 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: Dated: (SIGNATURE) (ADDRESS) (TAX IDENTIFICATION NUMBER)
SUBSCRIPTION FORM. 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 -------------------------------- -------------------------------- -------------------------------- (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. Dated: X -------------------- -------------------- -------------------- -------------------- Address -------------------- Social Security or Taxpayer Identification Number ------------------- Signature Guaranteed
SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________
SUBSCRIPTION FORM. To ChaseMellon Shareholder Services The Warrant Agent Attention: The undersigned hereby irrevocably elects to exercise the right of purchase represented by the within Warrant(s) for, and to purchase thereunder, ________________ shares of the stock provided for therein, and requests that certificates for such shares be issued in the name of and to: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- and, if said number of shares not be all the shares purchasable thereunder, that a new Warrant Certificate for the balance remaining of the shares purchasable under the within Warrant Certificate be registered in the name of the undersigned warrantholder or his assignee as below indicated and delivered to the address stated below. As the Exercise Price upon exercise of the Warrant(s) the undersigned encloses $_______________, by certified or official bank check. Dated:___________________________________________________________ Name of Warrantholder or Assignee:______________________________ Address:_________________________________________________________ -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Signature Guaranteed:___________________ Signature:________________________ THE SIGNATURE(S) SHOULD BE (NOTE: The above signature must correspond with GUARANTEED BY AN ELIGIBLE the name as written upon the face of this GUARANTOR INSTITUTION, GENERALLY, Warrant Certificate in every particular, BANKS, STOCK BROKERS, SAVINGS without alteration or enlargement or any INSTITUTIONS AND CREDIT change whatever, unless this Warrant UNIONS WITH MEMBERSHIP IN AN Certificate has been assigned.) APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM, PURSUANT TO S.E.C. RULE 17Ad-15. FORM OF ASSIGNMENT For value received and subject to the restrictions on transfer described in the Warrant Agreement under which this Warrant was issued, _______________________________________________ hereby sells, assigns, and transfers unto ____________________________ Warrants represented by the within Warrant Certificate, together with all right, title and interest therein, and does hereby irrevocable constitute and appoint ____________________________ __________________________________ attorney, to tra...
SUBSCRIPTION FORM. (To be Executed by the Optionee to Exercise the Rights to Purchase Stock evidenced by the foregoing Option) TO: MODAVOX, INC. The undersigned hereby exercises the right to purchase _______ shares of Common Stock covered by the attached Option in accordance with the terms and conditions thereof, and herewith makes payment of this Option Price of such shares in full. The undersigned represents and Options to you that the undersigned is acquiring such shares for the undersigned's own account with the intent of holding such shares for investment and without the intent of participating directly or indirectly in a distribution of such shares. _________________________________ By: _____________________________ Signature _________________________________ _________________________________ Address Dated: _________________.
SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part To: Granite Financial, Inc. (the "Company") The undersigned ______________________________ Please insert Social Security or other identifying number of Subscriber: ______________________________ hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ______________________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $___________________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: ___________________________________________________________________ Address: ___________________________________________________________________ Deliver to : _________________________________________________________________ Address: ___________________________________________________________________ and, if such number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: Signature _____________________________________________ Note: The signature on this Subscription Form must correspond with the name as written upon the face of this Warrant in every particular, without alteration or enlargement or any change whatever.
SUBSCRIPTION FORM. The undersigned hereby irrevocably subscribes for _______ shares of the Common Stock (the “Stock”) of Gxxxxxxxxxxx.xxx, Inc. (the “Company”) pursuant to and in accordance with the terms and conditions of the attached Warrant No. __ (the “Warrant”), and hereby makes payment of $_______ therefor by [tendering cash, wire transferring or delivering a certified check or bank cashier’s check, payable to the order of the Company] [surrendering _______ shares of Common Stock received upon exercise of the Warrant, which shares have an aggregate fair market value equal to such payment as required in Section 2 of the Warrant]. The undersigned requests that a certificate for the Stock be issued in the name of the undersigned and be delivered to the undersigned at the address stated below. If the Stock is not all of the shares purchasable pursuant to the Warrant, the undersigned requests that a new Warrant of like tenor for the balance of the remaining shares purchasable thereunder be delivered to the undersigned at the address stated below. In connection with the issuance of the Stock, I hereby represent to the Company that I am acquiring the 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, as amended (the “Securities Act”). I understand that if at this time the Stock has not been registered under the Securities Act, I must hold such Stock indefinitely unless the Stock is subsequently registered and qualified under the Securities Act or is exempt from such registration and qualification. I shall make no transfer or disposition of the Stock unless (a) such transfer or disposition can be made without registration under the Securities Act by reason of a specific exemption from such registration and such qualification, or (b) a registration statement has been filed pursuant to the Securities Act and has been declared effective with respect to such disposition. I agree that each certificate representing the Stock delivered to me shall bear substantially the same as set forth on the front page of the Warrant. I further agree that the Company may place stop transfer orders with its transfer agent same effect as the above legend. The legend and stop transfer notice referred to above shall be removed only upon my furnishing to the Company an opinion of counsel (reasonably satisfactory to the Company) to the effect that such legend may be removed. Date...
SUBSCRIPTION FORM. To: ___________________ Date: ___________________ The undersigned hereby subscribes for __________ Common Shares covered by this Warrant. The certificate(s) for such Common Shares (if certificated) shall be issued in the name of the undersigned or as otherwise indicated below. The undersigned hereby represents and warrants that the undersigned is acquiring such ownership interest for its own account for investment purposes only, and not for resale or with a view to distribution of such ownership interest or any part thereof. Signature: Name of Registration: Mailing Address:
SUBSCRIPTION FORM. To: MYECHECK, INC. (the "Company") And to: The Directors Thereof. Pursuant to the Share Purchase Warrant made the day of , 2008 the undersigned hereby subscribes for and agrees to take up _______________ common shares without par value (the "Shares") in the capital of the Company, at a price of $ 4.00 (USD) per Share for the aggregate sum of $_______________ (the "Subscription Funds"), and encloses herewith a certified cheque, bank draft or money order payable to the Company in full payment of the Shares. The undersigned (the "Subscriber") hereby requests that upon receipt of the Subscription Funds by the Company:
