Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 80 contracts
Samples: Underwriting Agreement (Better Choice Co Inc.), Underwriting Agreement (High Roller Technologies, Inc.), Underwriting Agreement (Oragenics Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 62 contracts
Samples: Meridian Waste Solutions, Inc., Meridian Waste Solutions, Inc., Meridian Waste Solutions, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 36 contracts
Samples: Underwriting Agreement (Lirum Therapeutics, Inc.), Underwriting Agreement (Lirum Therapeutics, Inc.), Placement Agency Agreement (Biovie Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 17 contracts
Samples: Underwriting Agreement (iSpecimen Inc.), Underwriting Agreement (Harbor Custom Development, Inc.), Creatd, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 13 contracts
Samples: Underwriting Agreement (Sidus Space Inc.), Underwriting Agreement (Sidus Space Inc.), Underwriting Agreement (Strong Global Entertainment, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ EXHIBIT B ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant ADSs.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Name: (Please Print) Address: (Please Print) Dated: _______________ __, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 13 contracts
Samples: Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd., Can-Fite BioPharma Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Securities Purchase Agreement (Nano Dimension Ltd.), Securities Purchase Agreement (Nano Dimension Ltd.), Securities Purchase Agreement (Nano Dimension Ltd.)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Underwriting Agreement (EzFill Holdings Inc), Underwriting Agreement (OMNIQ Corp.), Underwriting Agreement (BriaCell Therapeutics Corp.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Underwriting Agreement (Alta Global Group LTD), Underwriting Agreement (Azitra, Inc.), Underwriting Agreement (Alta Global Group LTD)
Accredited Investor. If the Warrant is being exercised via cash exercise, the 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 11 contracts
Samples: Underwriting Agreement (Innovation Beverage Group LTD), Warrant Agreement (Tharimmune, Inc.), Underwriting Agreement (Tharimmune, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 11 contracts
Samples: Securities Purchase Agreement (Generex Biotechnology Corp), Securities Purchase Agreement (Generex Biotechnology Corp), Airguide, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: ________________________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 10 contracts
Samples: Kingold Jewelry, Inc., Bioxytran, Inc, Bioxytran, Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [amended. SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 7 contracts
Samples: Common Stock Purchase Warrant (OverNear, Inc.), Preferred Stock Purchase Warrant (OverNear, Inc.), OverNear, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 6 contracts
Samples: Underwriting Agreement (Forza X1, Inc.), Underwriting Agreement (EzFill Holdings Inc), Underwriting Agreement (EzFill Holdings Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D D, promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ Date: ___________________________________________________________________________________________ ANNEX B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, ___________ Holder’s Signature: _______________________________ Holder’s Address: _______________________________ _______________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Common Stock Purchase Warrant (Theralink Technologies, Inc.), Enochian Biosciences Inc, Common Stock Purchase Warrant (Amesite Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. Name of Investing EntityHolder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityHolder: ____________________________________________ Name of Authorized Signatory: _______________Signatory (if Holder is an entity): ____________________________________________ Title of Authorized Signatory: __________________Signatory (if Holder is an entity): __________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ _________________, whose address is _______________________________________________________________. _______________ _______________________________________________________________ _______________. Dated: ______________, _______ Holder’s Name: _________________________________________ Holder’s Signature: _________________________________________ Holder’s Address: _________________________________________ _________________________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Assignment Form (Echo Therapeutics, Inc.), Tagalder Global Investment, Inc., Tagalder Global Investment, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 5 contracts
Samples: Underwriting Agreement (Rise Oil & Gas, Inc.), Underwriting Agreement (Azitra Inc), Perfect Moment Ltd.
Accredited Investor. If Unless the Warrant is being exercised via cash exerciseexercise pursuant to a cashless exercise in accordance with Section 2(c) of the Warrant or unless the Warrant Shares are registered under the Securities Act of 1933, as amended (the "Securities Act"), the undersigned represents it is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended Act. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 5 contracts
Samples: Zoom Technologies Inc, Zoom Technologies Inc, Zoom Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Snow Lake Resources Ltd.), Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 4 contracts
Samples: MeeMee Media Inc., Wifimed Holdings Company, Inc., Aurelio Resource Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________________________________________ Name of Authorized Signatory: ________________________________________________________________________________________________ Title of Authorized Signatory: _________________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Virios Therapeutics, LLC), Underwriting Agreement (Catasys, Inc.), Underwriting Agreement (Catasys, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Placement Agency Agreement (Akers Biosciences Inc), Akers Biosciences Inc, Toughbuilt Industries, Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 4 contracts
Samples: Underwriting Agreement (Marpai, Inc.), Odd Burger Corp, Nuvectis Pharma, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________ Name of Authorized Signatory: _________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: www.sec.gov, H & H Imports, Inc., H & H Imports, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: MetaStat, Inc., Photovoltaic Solar Cells, Inc., Peoples Liberation Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: Red Metal Resources, Ltd., Digital Angel Corp, Digital Angel Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ . Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 3 contracts
Samples: Underwriting Agreement (MR2 Group, Inc.), Underwriting Agreement (MR2 Group, Inc.), MR2 Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 3 contracts
Samples: ONCOSEC MEDICAL Inc, Lilis Energy, Inc., Celsion CORP
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 3 contracts
Samples: Exchange Agreement (Protea Biosciences Group, Inc.), Protea Biosciences Group, Inc., Protea Biosciences Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exerciseexercise and no registration statement covering the issuance of the Warrant Shares is effective, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 3 contracts
Samples: Silynxcom Ltd., Sushi Ginza Onodera, Inc., Silynxcom Ltd.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [/ _______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Maxwell Resources, Inc., Fluoropharma Medical, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrant, execute this executethis form and supply required information. Do not use this form to exercise the warrant.) FOR VALUE RECEIVED, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Proteonomix, Inc., Proteonomix, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Biovie Inc.), Underwriting Agreement (Biovie Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [___________] all of or [____________] shares of the foregoing Series B Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Phytomedical Technologies Inc, Phytomedical Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is EXHIBIT B ASSIGNMENT FORM (To assign the foregoing Warrant, execute this form and supply required information. Do not use this form to purchase Warrant ADSs.) FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned to Name: ______________________________________ (Please Print) Address: _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Midatech Pharma PLC, Midatech Pharma PLC
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Jayhawk Energy, Inc., Jayhawk Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Accredited Investor. If the Underwriter’s Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Underwriter’s Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Harbor Custom Development, Inc.), Underwriting Agreement (Harbor Custom Development, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Parkview Group Inc, Cord Blood America, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: _______________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Rennova Health, Inc.), Underwriting Agreement (Rennova Health, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. The Warrant Shares shall be delivered to the following DWAC Account Number or by physical delivery of a certificate to: [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Eyegate Pharmaceuticals Inc, Eyegate Pharmaceuticals Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________ Original Date of Issuance: October 5, 2006 Reissuance Date: December 19, 2007 Warrant No.: ___________________ Expires: October 5, 2011 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ ______________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Chembio Diagnostics, Inc., Siebert Lawrence A.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________________________________________________________________ Name of Authorized Signatory: ____________________________________________________________________________________________________________________ Title of Authorized Signatory: _____________________________________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to ________________________________________________________________________________ whose address is ______________________________________________________________________________________________. ______________________________________________________________________________________________ Dated: ______________, _______ Holder’s Signature: ______________________________________________ Holder’s Address: ______________________________________________ ______________________________________________ Signature Guaranteed: _____________________________________________________________________________
Appears in 2 contracts
Samples: Atlantic Syndication Network Inc, Atlantic Syndication Network Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ___________________________________________________ Name of Authorized Signatory: _____________________________________________________________________ Title of Authorized Signatory: ______________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (CEA Industries Inc.), Underwriting Agreement (Immuron LTD)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Blink Logic Inc., Reflect Scientific Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: ______________________________ _______________________________
Appears in 2 contracts
Samples: SQL Technologies Corp., SQL Technologies Corp.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 2 contracts
Samples: Underwriting Agreement (iSpecimen Inc.), NRX Pharmaceuticals, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ___________________________________________________________________________ Name of Authorized Signatory: _____________________________________________________________________________________________ Title of Authorized Signatory: ______________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Towerstream Corp), Underwriting Agreement (Towerstream Corp)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [_________] all of or [_________] shares of the foregoing Series B Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Entheos Technologies Inc, International Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ 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, [____] all of or [_______] shares of Series B Preferred Stock of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: _______:_____________________________________________________ Date: _______:_________________________________________________________________________ Original Date of Issuance: ___________ Reissuance Date: December 19, 2007 Warrant No.: _________________ Expires: ___________________ 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ ______________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Siebert Lawrence A., Chembio Diagnostics, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] _ all of or [_______] _ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: GeoVax Labs, Inc., Vuzix Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ____________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ 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, [____] all of or [_______] shares Common Stock Warrants of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: Underwriting Agreement (Fat Brands, Inc), Underwriting Agreement (Fat Brands, Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 2 contracts
Samples: Common Stock Purchase Warrant (As Seen on TV, Inc.), As Seen on TV, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: :________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: SIMPLICITY ESPORTS & GAMING Co, SIMPLICITY ESPORTS & GAMING Co
Accredited Investor. If the Warrant is being exercised via cash exercise, the 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 2 contracts
Samples: CytoMed Therapeutics LTD, Vivakor, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________________________________________________ Name of Authorized Signatory: ______________________________________________________________________________________________ Title of Authorized Signatory: _________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________________ whose address is _____________________________________________________________________. _____________________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: _____________________________________________
Appears in 1 contract
Samples: Common Stock Purchase (CareView Communications Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ EXHIBIT B 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Representative Warrant Agreement (Assure Holdings Corp.)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _ _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________________ Name of Authorized Signatory: __________________________________________________________________________ Title of Authorized Signatory: ___________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: ______________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Sub Urban (Sub-Urban Brands, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________ Name of Authorized Signatory: _________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: :___________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ____________________________________________________________________ Name of Authorized Signatory: :_______________________________________________________________________________________ Title of Authorized Signatory: :________________________________________________________________________________________ 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, [____[ ] all of or [_______[ ] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ __________whose address is _______________________________________________________________. ____________. Dated: , ___________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Underwriting Agreement (Vision Marine Technologies Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is to: _________________________________________________________ whose address is: _______. __________________________________________________ _________________________________________________________ Dated: , Holder’s Signature: ______________, _______ Holder’s Signature: _____________________________________ Holder’s Address: __________________________________________________________ __________________________________________________________ Signature Guaranteed: _______________________________________________________
Appears in 1 contract
Samples: Achillion Pharmaceuticals Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: :_________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ ____________________________________whose address is is: _______________________________________________________________. _________________________________ ________________________________________________________________________________________________ Dated: :______________, _________________________ Holder’s Signature: :_____________________________ Holder’s Address: :______________________________ ____________________________________________
Appears in 1 contract
Samples: Forza X1, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ___________________________________________________ Name of Authorized Signatory: _____________________________________________________________________ Title of Authorized Signatory: ______________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ __whose address is _______________________________________________________________. _______________________________________________________________ Dated: :_______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Marizyme Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to to: _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Lakeside Holding LTD
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: ______________________________ ______________________________
Appears in 1 contract
Samples: Underwriting Agreement (LMP Automotive Holdings, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. ________________________________________________________________________ Signature of Holder ________________________________________________________________________ Name of Investing Entity: Entity ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: Entity _________________________________________________________________________ Name of Authorized Signatory: Signatory _________________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ______Signatory __________________________________________________________________________ Tax ID Number ____________________ Date ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrant.) TO: Armada Oil, Inc. 00000 Xxxxxxxxxx Xxxx Suite 1100 Houston, Texas 77042 FOR VALUE RECEIVED, [___________] all of or [____________] shares of the foregoing Series D Warrant of Armada Oil, Inc. and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is is: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________. _______________________________________________________________ Tax ID number Dated: ______________, ____20___ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Tax ID Number _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _______________________________________________________________________________ Name of Authorized Signatory: _________________________________________________________________________________________________ Title of Authorized Signatory: __________________________________________________________________________________________________ Date: _____________________________________________________________________________________________________________________ EXHIBIT C 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 or [_______] shares of the [principal amount of the Senior Secured Convertible Notes] [Common Stock] [Subsequent Financing Securities] [Qualified Financing Securities] issuable upon exercise of the foregoing Warrant and all rights evidenced thereby are hereby assigned to ____________________________________________________________________ whose address is _______________________________________________________________. __________________ .. _________________________________________________________________________________ Dated: _______________ , _______ Holder’s Signature: ________________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Applied Dna Sciences Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________ Name of Authorized Signatory: __________________________________________________________________ Title of Authorized Signatory: ___________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _______________________________
Appears in 1 contract
Samples: Lilis Energy, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ________________________________________________________________ Signature of Authorized Signatory of Investing Entity: __________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: _____________________________________________________________ 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, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Underwriting Agreement (Immuron LTD)
Accredited Investor. If The undersigned represents that the Warrant is being exercised via cash exercise, representations set forth in Section 2.2(d) – (j) of the undersigned is an “accredited investor” Purchase Agreement are true and correct as defined in Regulation D promulgated under of the Securities Act date of 1933, as amended this Notice of Exercise. [SIGNATURE OF HOLDER] Name of Investing Entity: :_________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: :__________________________________________________________ Name of Authorized Signatory: :____________________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________Signature Guaranteed:
Appears in 1 contract
Samples: XCel Brands, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Rule 501(a) of Regulation D D, promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________________________________________ Name of Authorized Signatory: _____________________________________________________________________________________ Title of Authorized Signatory: _____________________________________________________________________________________ Date: _____________________________________________________________________________________ ANNEX B ASSIGNMENT FORM (To assign the foregoing warrant, execute this form and supply required information. Do not use this form to exercise the warrantWarrant.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: :______________, ___________ Holder’s Signature: _______________________________ Holder’s Address: _______________________________ _______________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Theralink Technologies, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: _________________________________________________ Title of Authorized Signatory: ___________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: ______________________________________ Holder’s Address: ______________________________________ ______________________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. The Warrant Shares shall be delivered to the following DWAC Account Number: ________________________________ ________________________________ ________________________________ [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: InspireMD, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _____________________________________________________ Name of Authorized Signatory: _______________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________:
Appears in 1 contract
Samples: PetVivo Holdings, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _____:__________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________:___________ Name of Authorized Signatory: __________:_________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Trans Lux Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Signature: Holder’s Address: _____________________________ _____________________________:
Appears in 1 contract
Samples: Underwriting Agreement (Harbor Custom Development, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: ___________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________________ Name of Authorized Signatory: ________________________________________________________________________ Title of Authorized Signatory: ________________________________________________________________________ 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, [____] all of or [_______] shares ADSs of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Samples: Mobilicom LTD
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [_________] all of or [_________] shares of the foregoing Series A Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Entheos Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Xxxxxx's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Spindle, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is either (i) an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended, or (ii) not a “U.S. Person” as such term is defined in Regulation S promulgated under the Securities Act of 1933, as amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ Date: ________________________________________________________________________________________ ASSIGNMENT FORM (To assign the foregoing warrantWarrant, execute this form and supply required information. Do not use this form to exercise the warrantpurchase shares.) FOR VALUE RECEIVED, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Name: exercise (Please Print) Address: (Please Print) Phone Number: Email Address: Dated: _______________ __, _______ Holder’s Signature: _______:______________________ Holder’s Address: :_____________________________ _____________________________
Appears in 1 contract
Samples: SONDORS Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: ______________________________ _______________________________
Appears in 1 contract
Samples: Underwriting Agreement (Harbor Custom Development, Inc.)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned certifies that it is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ______________________________________________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________________________________________________ Name of Authorized Signatory: __________________________________________________________________________________________________________ Title of Authorized Signatory: ___________________________________________________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ 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, _________ shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _________________________whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Zurvita Holdings, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, 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: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________
Appears in 1 contract
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended [SIGNATURE OF HOLDER] amended. Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ Date: ________________________________________________________________________________ Exhibit 4.1 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 or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is to: ____________________________________________________ whose address is: ____________. ________________________________________ ____________________________________________________ Dated: ___________________, ______________ Holder’s Signature: ____________________________________________________ Holder’s Address: ____________________________________________________ ____________________________________________________ Signature Guaranteed: ____________________________________________________
Appears in 1 contract
Samples: Innovate Biopharmaceuticals, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Ecosphere Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ____________________________________________________________________ Signature of Authorized Signatory of Investing Entity: :______________________________________________ Name of Authorized Signatory: ________________________________________________________________ Title of Authorized Signatory: _________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ ______________whose address is _______________________________________________________________. ____________________ ___________________________________________________________________________________ Dated:____________________ Holder’s Signature: ______________, _______ Holder’s Signature: ________________________________________ Holder’s Address: _____________________________________________________________ ______________________________________________________________ Signature Guaranteed:_____________________________________________________________________________
Appears in 1 contract
Samples: Common Stock Purchase (American Defense Systems Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ____________________________________________________________________ Signature of Authorized Signatory of Investing Entity: ______________________________________________ Name of Authorized Signatory: ________________________________________________________________ Title of Authorized Signatory: _________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant (or the specified portion thereof in cases of partial assignment) and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is ________________________________________________________________ . ___________________________Portion of Warrant to be assigned: ____________________________________ Dated: _______________ , _______ Holder’s Signature: _____________________________ HolderXxxxxx’s Address: _____________________________ _____________________________Signature Guaranteed:
Appears in 1 contract
Samples: Common Stock Purchase Warrant (Raser Technologies Inc)
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: _______________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [/ _______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Fluoropharma Medical, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: World Moto, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: ________________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Raser Technologies Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: _______________, _______ Holder’s 's Signature: _________________________________ Holder’s 's Address: __________________________________ __________________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Indoor Harvest Corp
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Aethlon Medical Inc
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: ________________________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is ________________________________________________________________ . _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Lithium Exploration Group, Inc.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing EntityWarrant Holder: ________________________________________________________________________ Signature of Authorized Signatory of Investing EntityWarrant Holder: _________________________________________________ Name of Authorized Signatory: ___________________________________________________________________ Title of Authorized Signatory: ____________________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. _______________________________________________________________ Dated: ______________, _______ Holder’s Signature: _____________________________ Holder’s Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Cerebain Biotech Corp.
Accredited Investor. If the Warrant is being exercised via cash exercise, the The undersigned is an “"accredited investor” " as defined in Regulation D promulgated under the Securities Act of 1933, as amended amended. [SIGNATURE OF HOLDER] Name of Investing Entity: _______________________________________________________________ Signature of Authorized Signatory of Investing Entity: _________________________________________ Name of Authorized Signatory: ___________________________________________________________ Title of Authorized Signatory: ____________________________________________________________ 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, [____] all of or [_______] shares of the foregoing Warrant and all rights evidenced thereby are hereby assigned to _______________________________________________ whose address is _______________________________________________________________. ______ _____________________________________________________________________ Dated: ______________, _______ Holder’s 's Signature: _____________________________ Holder’s 's Address: _____________________________ _____________________________ Signature Guaranteed: ___________________________________________
Appears in 1 contract
Samples: Us Dataworks Inc
