FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) TO: VERADIGM INC. The undersigned hereby irrevocably elects to exercise ______ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name of and delivered to: Please insert social security or other identifying number: ______________________ ________________________________________________________________ (Please print name and address) ________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: ______________________ (Please print name and address) _________________________________________________________________ Dated: ______________, _______ Signature Signature Guaranteed:
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.)
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) To: SERV-TECH, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Rights Certificate to purchase the Units issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that the certificates for shares of Common Stock (or other securities) constituting such Units be issued in the name of and delivered to: Please insert social security or other taxpayer identification number:________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ If such number of rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other taxpayer identification number:________________________ _______________________________________________________________________________ (Please print name and address) _______________________________________________________________________________ _______________________________________________________________________________ Dated:_________________, 19___ ___________________________________ Signature Signature Guaranteed: (Signatures must be guaranteed by a commercial bank or trust company or a member firm of the New York Stock Exchange.) 52 Certificate The undersigned hereby certifies by checking the appropriate boxes that: (1) the Rights evidenced by this Rights Certificate / / are / / are not being exercised by or on behalf of a Person who is or was an Acquiring Person or an Affiliate or Associate of any such Person (as such terms are defined in the Rights Agreement); and (2) after due inquiry and to the best knowledge of the undersigned, it / / did / / did not acquire the Rights evidenced by this Rights Certificate from any Person who is, was or became an Acquiring Person or an Affiliate or Associate of any such Person. Dated: , 19 ---------------- --- ---------------------------------- Signature Signature Guaranteed: (Signatures must be guaranteed by a commercial bank or trust company or a member firm of the New York Stock Exchange.)
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Rights Certificate.) (Please print name and address) (Please print name and address)
FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) TO: DOVER DOWNS GAMING & ENTERTAINMENT, INC. The undersigned hereby irrevocably elects to exercise ______________________________________ Rights represented by this Right Certificate to purchase the shares of Common Stock issuable upon the exercise of such Rights and requests that certificates for such share(s) be issued in the name: ______________________________________________________ (Please print name and address) Please insert social security or other tax identifying number If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: ______________________________________________________ (Please print name and address) Please insert social security or other tax identifying number _________________________________________ Dated: ______________ ____, 20_______ ______________________ Signature (Signature must conform in all respects to name/s of holder/s as specified on the face of this Right Certificate) Signature Guaranteed: Signatures must be guaranteed by an "eligible guarantor institution" as defined in Rule 17Ad-15 promulgated under the Securities Exchange Act of 1934, as amended. The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To:______________________ The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person or such other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or such other securities of the Company or of any other person or such other property as may be issuable upon the exercise of the Rights) be issued in the name of and delivered to: (Please print name and address) Please insert social security or other identifying number: If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: (Please print name and address) Please insert social security or other identifying number: Dated _____________, ______. Signature Signature Guaranteed: The undersigned hereby certifies by checking the appropriate boxes that:
FORM OF ELECTION TO PURCHASE. (To be executed by the Warrant Holder to exercise the right to purchase shares of Common Stock under the foregoing Warrant)
FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:
FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Rights Certificate.) To: The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate to purchase the shares of Preferred Stock issuable upon the exercise of the Rights (or such other securities of the Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of and delivered to: (Please print name and address) Please insert social security or other identifying number: If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number: Dated: , Signature Signature Guaranteed:
