Common use of FORM OF ELECTION TO PURCHASE Clause in Contracts

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Omega Worldwide Inc), Omega Worldwide Inc

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FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. SELECT MEDICAL CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 insert social security or other 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) Date:______________ , 19__ ______________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: Certificate :__________________________ Signatures must be guaranteed by a member firm of a registered United States national securities exchange, a member of the National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States. CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Select Medical Corp), Rights Agreement (Select Medical Corp)

FORM OF ELECTION TO PURCHASE. (a) (To be executed if holder desires desire to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDESEQUUS PHARMACEUTICALS, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:___________________, 19_________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ _______. _______________________ Signature Signature Guaranteed: Signatures must be guaranteed by a bank, broker, dealer, credit union or savings association or other entity that is a member in good standing of a signature guarantee medallion program approved by the Securities Transfer Association, Inc. Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Sequus Pharmaceuticals Inc), Rights Agreement (Sequus Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo Owens Corning: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably herexx xxrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:_____________________________________exer cise _______________ ______________________Rights represented by this Right Cer tificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certifi cates for such shares be issued in the name of: Xxease insert social security or other identifying number __________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:__________________________________________________________ ______________________If such number of Rights shall not be all the Rights evi denced 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 insert social security or other identifying number __________________________________________________________ (Please print name and address) Date:______________ , 19__ ____________________________________________ Dated:__________________, ____ [Form of Election to Purchase -- continued] __________________________ Signature (Signature Guaranteed: Certificate The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Right Certificate.)

Appears in 2 contracts

Samples: Rights Agreement (Owens Corning), Rights Agreement (Owens Corning)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEXXXX, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name ofof 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 represented evidenced by this Right Rights Certificate, a new Right 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) Date:______________________________________________________________________________ Dated: ___________________, 19______ __________________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking an eligible guarantor institution (including banks, stockbrokers, savings and loan associations, clearing agencies and credit unions with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the appropriate boxes that:Securities and Exchange Commission under the Securities Exchange Act of 1934, as amended.

Appears in 2 contracts

Samples: Rights Agreement (Culp Inc), Rights Agreement (Culp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Right Certificate.) ToTO: OMEGA WORLDWIDEDOVER DOWNS GAMING & ENTERTAINMENT, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ __________________________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 represented 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 insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Please insert social security or other tax identifying number ______________ , 19__ ______________________________ 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: Certificate 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:

Appears in 2 contracts

Samples: Rights Agreement (Dover Downs Gaming & Entertainment Inc), Rights Agreement (Dover Downs Gaming & Entertainment Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. CD Radio Inc. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Certificate to purchase the Preferred Series B Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person which entity that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: 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 Right Certificate, a new Right 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) ___________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Cd Radio Inc), Rights Agreement (Cd Radio Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. Pericom Semiconductor Corporation The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: 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 Right Certificate, a new Right Certificate for the balance remaining 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) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:Dated: Signature Signature Medallion Guaranteed: ______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking an “eligible guarantor institution” as defined in Rule 17Ad-15 promulgated under the appropriate boxes that:Securities Exchange Act of 1934, as amended.

Appears in 2 contracts

Samples: Rights Agreement (Pericom Semiconductor Corp), Rights Agreement (Pericom Semiconductor Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right CertificateTO BE EXECUTED IF HOLDER DESIRES TO EXERCISE THE RIGHT CERTIFICATE.) To: OMEGA WORLDWIDETo FAIRMARKET, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ____________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number:: ____________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: _________, __ __________________________________ , 19__ _________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:______________________________

Appears in 2 contracts

Samples: Shareholder Rights Agreement (Fairmarket Inc), Shareholder Rights Agreement (Fairmarket Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.Warrants) ToTO: OMEGA WORLDWIDEVION PHARMACEUTICALS, INC. The undersigned hereby irrevocably elects to exercise Warrants represented by this Warrant Certificate to purchase __________ Rights represented by this Right Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) Warrants and requests that certificates for such shares of Common Stock be issued in the name of: Please insert social security or other identifying number:____________________________________ Please insert social security, tax identification or other identifying number ___________________________ ___________________________ ___________________________ If such number of Warrants is not all the Warrants evidenced by this Warrant Certificate, a new Warrant Certificate for the balance remaining of such Warrants shall be registered in the name of and delivered to: Please insert social security, tax identification or other identifying number ___________________________ ___________________________ ___________________________ (Please print name and address) Dated:________________________ ________________________________________________________________________________ Signature (Please print name and address) If such number of Rights shall not be Signature must conform in all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the respects to name of and delivered to: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and addressholder as specified on the face of the Warrant Certificate) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Warrant Agreement (Vion Pharmaceuticals Inc), Warrant Agreement (Vion Pharmaceuticals Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. Xxxx-Xxxxx Company: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ ___Rights represented by this Right Certificate to purchase the shares of Common Stock issuable upon the exercise of such 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: _____________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:_____: _______________________________________________ ___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) Date:Please insert social security or other identifying number: ______________ , 19__ __________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies certifies, by checking marking the appropriate boxes boxes, that:

Appears in 2 contracts

Samples: Stockholder Rights Agreement (Nash Finch Co), Stockholder Rights Agreement (Nash Finch Co)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Rights represented by the this Right Certificate.) ToTo Consolidated Graphics, Inc.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ___________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be share(s) of Preferred Stock (or such other securities)be issued in the name ofname: Please insert social security or other identifying number:________________________________________________________________________________ (Please insert social security or other identifying number) ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________ 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 insert social security or other identifying number) ________________________________________________________________________________ (Please print name and address) Date:________________________________________________________________________________ Dated: __________________, 19__ _____. ____________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking a member firm of a registered national securities exchange, a member of the appropriate boxes that:National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.

Appears in 2 contracts

Samples: Rights Agreement (Consolidated Graphics Inc /Tx/), Rights Agreement (Consolidated Graphics Inc /Tx/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) ToTo ______________: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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:__________________________________________________________________________ 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) Date:__________________________________________________________________________ Dated: _________, 1920____ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Forgent Networks Inc), Rights Agreement (Forgent Networks Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: OMEGA WORLDWIDE, VERADIGM INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number:______________________________: ______________________ ________________________________________________________________ (Please print name and address) _________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:____________________________________________________ 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) _________________________________________________________________ (Please print name and address) Date:______________ , 19__ Dated: _______________________, _______ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Veradigm Inc.), Rights Agreement (Veradigm Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, ANCHOR BANCORP WISCONSIN INC. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Certificate to purchase the Preferred Series A Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person which entity that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:: ______________________________ ___________________________________________________________ (Please print name and address) ___________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Certificate, a new Right 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: ____________________, [19][20]__ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Anchor Bancorp Wisconsin Inc), Rights Agreement (Anchor Bancorp Wisconsin Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo TWEETER HOME ENTERTAINMENT GROUP, INC. .: The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:of _________________________: Please insert social security or other identifying taxpayer number: ________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11.1.2 of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to ______________ , 19_______: Please insert social security or other identifying taxpayer number: Please insert social security or other identifying taxpayer number: ________________________________ ________________________________ Signature ________________________________ ________________________________ ________________________________ (Please print name and address) Signature:______________________ Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc), Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDEORAPHARMA, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the shares of Series E Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 insert social security or other 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) Date:______________ , 19__ ______________________________ (Please insert social security or other identifying number) Dated:_______________, _____ _______________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies ________________________ Signatures must be guaranteed by checking a member firm of a registered United States national securities exchange, a member of the appropriate boxes that:National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.

Appears in 2 contracts

Samples: Rights Agreement (Orapharma Inc), Rights Agreement (Orapharma Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. Swift Energy Company The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series A Junior Participating Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series A Junior Participating Preferred Stock (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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date_____________________________________________________ Please insert social security or other identifying number:______________ , 19___________ Dated:___________________ ____________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Swift Energy Co), Rights Agreement (Swift Energy Co)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the Right this Rights Certificate.) To: OMEGA WORLDWIDETHE BISYS GROUP, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Right Rights Certificate to purchase the Preferred Shares shares of Company Common Stock issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Company Common Stock (or such other securities which may be issuable upon the exercise of the Rights) be issued in the name ofof and delivered to: Please insert social security or other identifying number:: ____________________________ _______________________________________________________________________________ (Please print name) _______________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all of the Rights represented evidenced by this Right Rights Certificate, a new Right 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) _______________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: ______________ ______, 19_______ __Signature: ____________________________ (Sign exactly as your name appears on the other side of this Rights Certificate) Signature Signature GuaranteedGuarantee: Certificate The undersigned hereby certifies by checking the appropriate boxes that:___________________

Appears in 2 contracts

Samples: Rights Agreement (Bisys Group Inc), Rights Agreement (Bisys Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the Right this Rights Certificate.) To: OMEGA WORLDWIDE, INC. MIM CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Right Rights Certificate to purchase the Preferred Shares Units issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units (or such other securities which may be issuable upon the exercise of the Rights) be issued in the name ofof and delivered to: Please insert social security or other identifying number:: ________________________________ __________________________________________________ (Please print name) __________________________________________________ __________________________________________________ (Please print address) If such number of Rights shall not be all of 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 addressname) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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 address) Dated: ______________________________________, Signature: _______________________________________ (Please print Sign exactly as your name and addressappears on the other side of this Rights Certificate) Date:______________ , 19__ Signature Guarantee: ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 2 contracts

Samples: Rights Agreement (Mim Corp), Rights Agreement (Mim Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Right Certificate.) ToTO: OMEGA WORLDWIDE, FXCM INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares share(s) be issued in the name offollowing name: Please insert social security or other identifying number:______________________________________________________________ ________________________________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________________________________ If such number of Rights shall not be all the Rights represented 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 insert social security or other identifying number:______________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:_________________________ (Please print name and address) ________________________________________________________________________________________________________ Dated: ___________ ___, 19_____ ______________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Certificate Signatures must be guaranteed by a participant in a Medallion Signature Guarantee Program at a guarantee level acceptable to the Corporation’s Rights Agent. The undersigned hereby certifies that the Rights evidenced by checking this Right Certificate are not, and never have been, beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the appropriate boxes that:Rights Agreement). ______________________________ Signature

Appears in 2 contracts

Samples: Rights Agreement (FXCM Inc.), Rights Agreement (FXCM Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDExXXxX*s, INC. Inc. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares or portion thereof of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number:number _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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:number _______________________________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature (Please print name and address) Dated: Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (dELiAs, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. AmeriSource Health Corporation The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ Rights represented by this Right Certificate to purchase the Common Shares issuable upon the exercise of such Rights (or such other securities of the Company or of any other person which may be issuable upon exercise of the Rights) and requests that certificates for such securities be issued in the name of and delivered to: ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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 insert social security or other 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) Date:________________________________________________________________________________ (Please insert social security or other identifying number) Dated: _______________, 19_____ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies :_______________________ Signatures must be guaranteed by checking a member firm of a registered United States national securities exchange, a member of the appropriate boxes that:National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.

Appears in 1 contract

Samples: Rights Agreement (Amerisource Health Corp/De)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEAlbexxxxx'x, INCXxc. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: 75 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Albertsons Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo BAY APARTMENT COMMUNITIES, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ______________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ______________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:____________________________________________________ _________________________________ Signature Signature Guaranteed: ________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Bay Apartment Communities Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.RIGHTS CERTIFICATE) To: OMEGA WORLDWIDE, INCRENEX CORP. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance remaining 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) Date________________________________________________________________________________ Dated:______________ , 19____________ ____________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this RIGHTS CERTIFICATE) Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Renex Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDED & K HEALTHCARE RESOURCES, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:____________________________________________________ _____________________________________________________ (Please print name and address) _____________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented 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 insert social security or other identifying number:____________________________________________________ _____________________________________________________ (Please print name and address) _____________________________________________________ (Please print name and address) DateDated:______________ , 19________________ Signature___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking a member firm of a registered national securities exchange, a member of the appropriate boxes that:National Association of Securities Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States.

Appears in 1 contract

Samples: Rights Agreement (D & K Healthcare Resources Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEUNITED DOMINION REALTY TRUST, INC. .: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series C Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name ofof and delivered to: Please insert social security or other identifying number:____________________________________________________ __number ______________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:______________________________________________________________________________ __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) Date:______________ , 19__ ________________________________________________________________ (Please print name and address) 1 Date: _______________, ____ -------------------------------- Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (United Dominion Realty Trust Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo BROOKTROUT TECHNOLOGY, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: __________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: _____________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:________________________________________________, ____ _________________________________ Signature Signature Guaranteed: ________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Brooktrout Technology Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented Represented by the Right Second Rights Certificate.) To: OMEGA WORLDWIDE, INCWGNB CORP. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security of and delivered to (please type or print): Social Security or other identifying number:: [ _________________ ] Name and Address: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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:Name and Address: ___________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ___________________________________________________________________ Signature Signature GuaranteedSocial Security or other identifying number: ______________________ Dated: ____________________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (WGNB Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETO MILLERS AMERICAN GROUP, INC. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares share(s) be issued in the name offollowing name: Please insert social security or other identifying number:: ____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented 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 insert social security or other identifying number:: ____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: ______________ , 19. __ __________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Medallion Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Millers Mutual Fire Insurance Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDEHyseq, INC. Inc. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:___________number _________________________________________ (Please print name and address) _________________________________________ 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 insert social security or other identifying number ____________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:Dated: ______________ , 19_____ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies ______________________________ Signatures must be guaranteed by checking an "eligible guarantor institution" as defined in Rule 17Ad-15 promulgated under the appropriate boxes that:Securities Exchange Act of 1934, as amended.

Appears in 1 contract

Samples: Rights Agreement (Hyseq Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. CTPartners Executive Search Inc. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series A Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series A Preferred Stock (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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date_____________________________________________________ Please insert social security or other identifying number:______________ , 19___________ Dated:___________________ ____________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Ctpartners Executive Search Inc.)

FORM OF ELECTION TO PURCHASE. (a) (To be executed if holder desires desire to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEICU MEDICAL, INC. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:___________________, _____. _________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking a bank, broker, dealer, credit union or savings association or other entity that is a member in good standing of a signature guarantee medallion program approved by the appropriate boxes that:Securities Transfer Association, Inc.

Appears in 1 contract

Samples: Rights Agreement (Icu Medical Inc/De)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo T CELL SCIENCES, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:____________________________________________________ ____________________________________________ Signature Signature Guaranteed: _____________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Avant Immunotherapeutics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INCOCTEL CORP. The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date:______________ , 19__ ______________________________ (Please print social security or other identifying number) Dated:_______________, _____ ________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:__________________________

Appears in 1 contract

Samples: Rights Agreement (Octel Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. Southwest Water Company The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:____________________________________________________________ ____________________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 insert social security or other identifying number ____________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________________________ Dated: __________________ _________________________ Signature Signature Guaranteed: Certificate ________________________ 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:

Appears in 1 contract

Samples: Rights Agreement (Southwest Water Co)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEInterface, INC. Inc. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates (or registrations in uncertificated book-entry form on the books of the Company) for such shares securities be issued in the name ofof and delivered to: Please insert social security or other identifying number:number ____________________________________________________ _______________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:____________________________________________________ ______________________________________________________________________________________ (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) Date:insert social security or other identifying number _____________________________________________ (Please print name and address) _____________________________________________ Dated: ____________________, 19_______ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:Exhibit C

Appears in 1 contract

Samples: Rights Agreement (Interface Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise :_________________ The undersigned hereby irrevocably elects to exercise Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date_______________________________________________________________________________ Please insert social security or other identifying number:______________ , 19____________ _____________________________________________________ Dated: ____________ __, ____ ----------------------------- Signature Signature Guaranteed: Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Eldertrust)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEXXXXXXX ASSOCIATES, INC. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the Units of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name ofof and delivered to: (Please insert social security or other identifying number: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 he registered in the name of and delivered to: (Please print name and address) _______________________________ Please insert social security or other identifying number: _________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Gilbert Associates Inc/New)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo ALBANY MOLECULAR RESEARCH, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number:____________________: ________________________________ _______________________________________________________________________________________ (Please print name and address) Date:Dated: ______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies ______________________________ Signatures must be guaranteed by checking a participant in the appropriate boxes that:Medallion Signature Guarantee Program at a guarantee level acceptable to the Company’s Transfer Agent.

Appears in 1 contract

Samples: Shareholder Rights Agreement (Albany Molecular Research Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented evidenced by the Right Certificate.) ToNew Century Energies, Inc.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Certificate to purchase the shares of the Preferred Shares Stock issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other taxpayer identifying number:number -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- 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 insert social security or other taxpayer identifying number (Please print name and address) Dated: ________________________________________________, ____ __________________________---------------------------------------- Signature Signature Guaranteed: ______________________________________________________ (Please print name and address) If such number Signatures must be guaranteed by a commercial bank or trust company or by a member of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:New York Stock Exchange.)

Appears in 1 contract

Samples: Rights Agreement (New Century Energies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, HOLLINGER INTERNATIONAL INC. The undersigned hereby irrevocably elects irrevoxxxxx xxxcts to exercise _________ Rights represented by this Right Certificate to purchase the Preferred Series Z Shares (or fractions thereof) issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person which entity that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:____: ________________________________________________ ________(Please print name and address) ________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Certificate, a new Right 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) ________________________________________________________________________ (Please print name and address) Date:Dated: ______________ , 19__ _____, 20__ _________________________ Signature Signature Guaranteed: Certificate CERTIFICATE ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Hollinger International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo Urstadt Bxxxxx Properties Inc.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:________________________________ Rights represented by this Right Certificate to purchase the Preferred Shares (or other securities) issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number: _____________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:______________________________________________________________________________ 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 insert social security or other identifying number: __________________ ________________________________________________________________________________ (Please print name and address) Date:______________________________________________________________________________ Dated: _____________________, 19__________ ___________________________________ Signature (Signatures to the foregoing Election to Purchase and the following certificate must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Urstadt Biddle Properties Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDESOFTWARE PUBLISHING CORPORATION HOLDINGS, INC. The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- (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 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 identifying number: _____________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:________________________________________________, ____ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ -------------------------------------------------------------------------------- Signature Signature Guaranteed: Certificate Signatures must be guaranteed by an eligible guarantor institution (a bank, stock broker, savings and loan association or credit union with membership in an approved signature guarantee program) pursuant to Rule 17Ad-15 of the Securities Exchange Act of 1934. -------------------------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by checking this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the appropriate boxes that:Rights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Software Publishing Corp Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo ChaseMellon Shareholder Services L.L.C.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of the such Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:__Name: __________________________________________________ Address: _______________________________________________ Social Security or Taxpayer I.D. No.: ______________________________________________ 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 an delivered to: Name: __________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toAddress: Please insert social security or other identifying number:____________________________________________________ __________________________________Social Security or Taxpayer I.D. No.: ______________________________________________ (Please print name and address) Date:Dated: ___________, ___ , 19___ __________________________________ Signature (Signature Guaranteed: Certificate The undersigned hereby certifies by checking must conform in all respects to name of holder as specified on the appropriate boxes that:face of this Right Certificate)

Appears in 1 contract

Samples: Rights Agreement (Coeur D Alene Mines Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDELOWE'S COMPANIES, INC. The .: Xxe undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Series A Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name ofof 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 represented by this Right Certificate, a new Right 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:_______________________________________________________________________________ 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) Date:_______________________________________________________________________________ (Please print name and address) Date: _______________, 19____ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Lowes Companies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Rights represented by Certificate other than pursuant to Section 11(a)(ii) of the Right CertificateRights Agreement.) To: OMEGA WORLDWIDEFIBERSTARS, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the one one-thousandths of a share of Preferred Shares Stock (or such other securities of the Company or any other Person) issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:___________________________________________________________________________________________ (Please insert social security or other identifying number) ___________________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:___________________________________________________________________________________________ If applicable, the Rights Certificate indicating the balance, if any, of such Rights which may still be exercised pursuant to Section 11(a)(ii) of the Rights Agreement shall be returned to the undersigned unless such Person requests that the Rights Certificate be registered in the name of and delivered to: ___________________________________________________________________________________________ Please insert social security or other identifying number (complete only if Rights Certificate is to be registered in a name other than the undersigned) ___________________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ _____________________________________________________________________________ Dated: ________________________, 20____. ________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking an Eligible Guarantor Institution, as defined in Rule 17Ad-15 under the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Fiberstars Inc /Ca/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: OMEGA WORLDWIDEXxxxxxxxx-UTI Energy, INC. Inc. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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:______________________________________________________________________________ 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) Date:_____________________________________________________________________________ Dated: ______________, 19_______ ______________________________ Signature Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Stockholder Rights Agreement (Patterson Uti Energy Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. ASARCO CYPRUS INCORPORATED: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number: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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:________________________________________________, ____ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Asarco Cyprus Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented evidenced by the Right this Rights Certificate.) To: OMEGA WORLDWIDE, INC. MIM CORPORATION The undersigned hereby irrevocably elects to exercise ________________ Rights represented evidenced by this Right Rights Certificate to purchase the Preferred Shares Units issuable upon the exercise of the Rights (or such other securities securities, cash or property of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units (or such other securities which may be issuable upon the exercise of the Rights) be issued in the name ofof and delivered to: Please insert social security or other identifying number:_________________________ ________________________________________ (Please print name) ________________________________________ ________________________________________ (Please print address) If such number of Rights shall not be all of 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 addressname) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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 address) Dated: ______________________________________, Signature: _____________________________________________________________________ (Please print Sign exactly as your name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking appears on the appropriate boxes that:other side of this Rights Certificate)

Appears in 1 contract

Samples: Rights Agreement (Mim Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEFURNITURE BRANDS INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Rights Certificate to purchase the Units of Series B Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which or such other property as may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units of Series B Preferred Stock (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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date_____________________________________________________ Please insert social security or other identifying number:______________ , 19___________ Dated:___________________ ____________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Furniture Brands International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEROMAC INTERNATIONAL, INC. The undersigned hereby irrevocably elects to exercise ___________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) Rights and requests that certificates for such shares be issued in the name ofof 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 represented by this Right Rights Certificate, a new Right Rights Certificate for the balance of such Rights shall be registered in the name of and delivered to: Form of Reverse Side of Rights Certificate -- continued Please insert social security or other identifying number:_____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:________________________________________________________________________________ Dated: ____________________ , 19____ ____________________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Romac International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. QUAKER FABRIC CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares securities be issued in the name ofof and delivered to: Please insert social security or other identifying number:____________________________________________________ _______________number (Please print name and address) _________________________________________________________________ (Please print name and addressaddress of transferee) If such number of Rights specified above shall not be all the Rights represented evidenced by this Right Certificate, the Rights Agent shall place an appropriate notation on this Right Certificate with respect to those Rights exercised or a new Right 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:____________________________________________________ _______________number (Please print name and address) _________________________________________________________________ (Please print name and addressaddress of transferee) Date:Dated: ______________ _, 19__ ________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Quaker Fabric Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right CertificateTO BE EXECUTED IF HOLDER DESIRES TO EXERCISE THE RIGHT CERTIFICATE.) ToTo IROBOT CORPORATION: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number:: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: _________, _____ ___________________________________ , 19__ __________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:__________________________________________________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Irobot Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEXxxxxxx, INC. Inc. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:____________________: ________________________________ __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) Date:______________________________________________________________________________ , 19Please insert social security or other identifying number: __ _______________________________ Signature Signature Guaranteed: guaranteed (by a member firm of The New York Stock Exchange or a commercial bank or trust company having an office or correspondent in New York City): Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Wellman Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo WARRXX XXXCORP, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: _____________________ -------------------------------------------------------------------------------- (Please print name and address) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Dated: ___________, ____ __________________________________________________________________ Signature Signature Guaranteed: _______________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Warren Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, UNI-MARTS INC. The undersigned hereby irrevocably elects to exercise __________________________ Rights represented by this Right Certificate to purchase the Preferred Shares Fractional Share issuable upon the exercise of the such Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the such Rights) and requests that certificates for such the shares of Common Stock be issued in the name of: Please insert social security or other identifying number:_____________number _______________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights represented 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 insert social security or other identifying number:_____________number _______________________________________ ________________________________________________________________________________ (Please print name and address) Date:________________________________________________________________________________ Dated: _________________, 19____ ________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies ____________________________ Signatures must be guaranteed by checking an eligible guarantor institution (a bank, stockbroker, savings and loan association or credit union with membership in an approved signature guarantee medallion program) pursuant to Rule 17Ad-15 of the appropriate boxes that:Securities Exchange Act of 1934.

Appears in 1 contract

Samples: Rights Agreement (Uni Marts Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDESOFTWARE PUBLISHING CORPORATION HOLDINGS, INC. The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (Please print name and address) Please insert social security or other identifying number: ___________________ If such number of Rights shall not be all the Rights represented 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 insert social security or other identifying number:_______________________________________________________________________________ _______________________________________________________________________________ __ (Please print name and address) Date:______________________________________________________________________________ , 19(Please print name and address) Please insert social security or other identifying number: ___________________ Dated: ________________, ____ _______________________________________________________________________________ Signature Signature Guaranteed: Certificate Signatures must be guaranteed by an eligible guarantor institution (a bank, stock broker, savings and loan association or credit union with membership in an approved signature guarantee program) pursuant to Rule 17Ad-15 of the Securities Exchange Act of 1934. _______________________________________________________________________________ The undersigned hereby certifies that the Rights evidenced by checking this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the appropriate boxes that:Rights Agreement).

Appears in 1 contract

Samples: Rights Agreement (Software Publishing Corp Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEKEY TECHNOLOGY, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented evidenced by this Right Rights Certificate, a new Right 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) Date_______________________________________________________________________________ Dated:______________ , 19_______________ _______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Key Technology Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. UNITED STATES STEEL CORPORATION: The undersigned hereby irrevocably elects to exercise ________ Rights exercise____________Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number:number ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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:number --------------------------- ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) DateDated:______________ , 19__ ,_______ ________________________ Signature Signature Guaranteed: Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Usx Corp)

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FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. CLECO CORPORATION The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the shares of $25 Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name ofof and delivered to: Please insert social security or other identifying number:____________________________________________________ number ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________ 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) Date:________________________________________________________________________________ Dated: ____________, 1920__ __________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking a member firm of a national securities exchange, a member of the appropriate boxes that:National Association of Securities Dealers, Inc., a commercial bank or trust company having an office or correspondent in the United States or another eligible guarantor institution (as defined pursuant to Rule 17Ad-15 under the Securities Exchange Act of 1934, as amended).

Appears in 1 contract

Samples: Rights Agreement (Cleco Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo CRITICARE SYSTEMS, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the one one-hundredth Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:number ____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________________________________________ 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 insert social security or other identifying number ________________________________________________________________________________________________________________ (Please print name and address) Date________________________________________________________________________________________________________________ Dated:______________ ___, 1920__ ________________________________ Signature Signature Guaranteed: Signatures must be guaranteed by a member firm of a registered national securities exchange, a member of the National Association of Securities Form of Reverse Side of Right Certificate -- continued Dealers, Inc., or a commercial bank or trust company having an office or correspondent in the United States. ------------------------------------------------------------------------------------------------------------------------------------- The undersigned hereby certifies that the Rights evidenced by checking this Right Certificate are not beneficially owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the appropriate boxes that:Rights Agreement). _______________________________

Appears in 1 contract

Samples: Rights Agreement (Criticare Systems Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Warrant Certificate.) To). TO: OMEGA WORLDWIDEMEDIA LOGIC, INC. CC: XXXXXX CAPITAL GROUP, LTD. 0000 Xxxxxx Xxxxxx, Xxxxx 000 Xxx Xxxxxx, Xxxxxxxxxx 00000 Attn: Xxxxxxx Xxxxxx Fax: (000) 000-0000 The undersigned hereby irrevocably elects to exercise ___Warrants represented by this Warrant Certificate to purchase _____ Rights represented by this Right Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) Warrants and requests that certificates for such shares be issued in the name of: (Please insert social security security, tax identification or other identifying number:_______________________) _____________________________ ____________________________________________________ _____________________________ (Please print name and address) If such number of Rights Warrants shall not be all the Rights represented Warrants evidenced by this Right Warrant Certificate, a new Right Warrant Certificate for the balance remaining of such Rights Warrants shall be registered in the name of and delivered to: Please insert social security security, tax identification or other identifying number:_______________________number _____________________________ ____________________________________________________ _____________________________ (Please print name and address) Date:Dated: ______________ ___________, 19_______ ___________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Warrant Certificate) Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Warrant Agreement (Media Logic Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEMMI COMPANIES, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number: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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying numberDated:____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Medallion Signature Guaranteed: Signature must be guaranteed by a commercial bank or trust company, broker, dealer, or other eligible institution which is a member in good standing of a medallion guaranty program approved by the Securities Transfer Association, Inc. Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Mmi Companies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented Represented by the Right Initial Rights Certificate.) To: OMEGA WORLDWIDE, INCWGNB CORP. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name of: Please insert social security of and delivered to (please type or print): Social Security or other identifying number:: [ __________________ ] Name and Address: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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:Name and Address: ___________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ___________________________________________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes thatSocial Security or other identifying number:_______________________ Dated:____________________

Appears in 1 contract

Samples: Rights Agreement (WGNB Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETO PHOTRONICS, INC. .: The undersigned hereby irrevocably elects to exercise _______________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security Social Security or other identifying number:____________________________________________________ ______. Please print name and address: ________________________________________________________________________________ (Please print .) 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 address) Date:______________ , 19__ delivered to: ______________________________ __________________________. (Please insert Social Security or other identifying number:_________________________________________________________. Please print name and address: _______________________________________________________________.) Date: Signature Signature Guaranteed: Certificate The undersigned hereby certifies Signatures must be guaranteed by checking the appropriate boxes thatan eligible guarantor institution (bank, stock broker or savings and loan association with membership in an approved signature medallion program). Date:

Appears in 1 contract

Samples: Section 382 Rights Agreement (Photronics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Series A Rights represented by the Right Certificate.) To: OMEGA WORLDWIDEFRUIT OF THE LOOM, INC. The undersigned hereby irrevocably elects to exercise _____________ Series A Rights represented by this Right Series A Rights Certificate to purchase the Preferred Shares issuable upon the exercise of the such Series A Rights (or such other securities of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Series A Rights shall not be all the Series A Rights represented evidenced by this Right Series A Rights Certificate, a new Right Series A Rights Certificate for the balance remaining of such Series A Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number:________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:________________________________________________________________________________ (Please insert social security or other identifying number) Dated: _________________________, 19__ ___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies __________________________________________________________ Signatures must be guaranteed by checking the appropriate boxes that:an Eligible Guarantor Institution as defined by SEC Rule 17Ad-15 (17 C.F.R. 240.17-Ad-15).

Appears in 1 contract

Samples: Rights Agreement (Fruit of the Loom Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INC. Maxar Technologies Inc. The undersigned hereby irrevocably elects to exercise __________________ Rights represented by this Right Certificate to purchase the Series A Preferred Shares issuable upon the exercise of the such Rights (or such other securities or property of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares stock (or such other securities or property of the Company or of any other Person which may be issuable upon the exercise of the Rights) be issued in the name of: Please insert social security of (or other identifying number:to, as the case may be): _____________________________________________________________ (Please print name and address) _____________________________________________________________ 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 insert social security or other identifying number_____________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:Dated: __________________ , 19__ Signature Signature Medallion 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, which is a member of a recognized Medallion Signature Signature Guaranteed: Certificate Guarantee Program. The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Tax Benefit Preservation Plan (Maxar Technologies Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Rights represented by the Right Certificate.) ToTO SONIC CORP.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock (or other securities) issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares share(s) be issued in the name offollowing name: Please insert social security or other identifying number:_: ___________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right Rights Certificate for the balance remaining 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) Date:________________________________________________________________________________ , 19Dated:____________ ___________________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Rights Certificate) Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Sonic Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. ADVANTA CORP.: The undersigned hereby irrevocably elects to exercise ________ Class [A][B] Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number: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) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) DateDated:___________ ,____ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Advanta Corp)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise the Rights represented by the Right Certificate.) ToTo Manatron, Inc.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights Stock (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Please insert social security or other tax identifying number:____________________________________________________ _________: _______________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:_______________________________________________________________________ _________If such number of Rights shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of remaining Rights shall be registered in the name of and delivered to: Please insert social security or other tax identifying number: _______________________________________________________________________ (Please print name and address) Date:_______________________________________________________________________ , 19Dated: ___________________ ____________________________________ Signature Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Manatron Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEGLASSBRIDGE ENTERPRISES, INC. The undersigned hereby irrevocably elects to exercise ________ __Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number:number ______________________________________________________ Please print name and address _________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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:number _____________________________________________________ Please print name and address __________ _______________________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Dated: __________, ________ Signature Signature Medallion Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: 382 Rights Agreement (GlassBridge Enterprises, Inc.)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo ANDOVER BANCORP, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: __________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number:: _____________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: _________, __ _____ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:____________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (Andover Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDECREE, INC. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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:: _____________________________________________________ _____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) Date:Please insert social security or other identifying number: _____________________________________________________ Dated: __________________, 1920__ __________________________________ Signature Signature Guaranteed: ________________________ Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cree Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEWOLVERINE WORLD WIDE, INC. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented evidenced by this Right Rights Certificate, a new Right 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) Date:___________________________________________________________________________ Dated: ______________, 19__ ___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Wolverine World Wide Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo MEDFORD BANCORP, INC. .: The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ____________________ _____________________________________________________________ (Please print name and address) _____________________________________________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ____________________ _____________________________________________________________ (Please print name and address) _____________________________________________________________ _____________________________________________________________ Dated: ____________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:____________________________________________________ _______________________________ Signature Signature Guaranteed: __________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Medford Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right CertificateTO BE EXECUTED IF HOLDER DESIRES TO EXERCISE THE RIGHT CERTIFICATE.) ToTo GENZYME TRANSGENICS CORPORATION: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: ------------------- ------------------------------------------------------------------------ ------------------------------------------------------------------------ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: -------------------- ----------------------------------------------------------------------- ----------------------------------------------------------------------- (Please print name and address) Dated: _________, __ ____________________________________________ ____________________________________________ Signature Signature Guaranteed: _____________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Genzyme Transgenics Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo INTERSTATE HOTELS CORPORATION: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:_____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right CertificateCertificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number:_____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) DateDated:______________ , 19__ ______ _________________________ Signature Signature Guaranteed: Certificate :_________________________ The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Interstate Hotels Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo the Company and the Rights Agent: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate and to purchase the Preferred Shares shares issuable upon the exercise of the such Rights (or such other securities of the Corporation 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: 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 Right Certificate, a new Right Certificate for the balance remaining 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) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:Dated: ______________ _, 1920__ __________Signature: ____________________ (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed: Certificate The undersigned hereby certifies (after due inquiry and to the best knowledge of the undersigned) by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Advanced Marketing Services Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEDAKOTA TELECOMMUNICATIONS GROUP, INC. The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:Dated: ______________ _, 19__ ___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Dakota Telecommunications Group Delaware Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo TWEETER HOME ENTERTAINMENT GROUP, INC. .: The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:of _________________________: Please insert social security or other identifying taxpayer number: ___________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11.1.2 of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to______________ , 19_______: Please insert social security or other identifying taxpayer number: Please insert social security or other identifying taxpayer number: ___________________________________ ___________________________________ Signature ___________________________________ ___________________________________ ___________________________________ (Please print name and address) Signature:_________________________ Signature Guaranteed: Certificate CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Tweeter Home Entertainment Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. NUI CORPORATION The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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: ___________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered toDated: Please insert social security or other identifying number:__________________________________________________, 20__ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Nui Holding Co)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDETo FIRST MID-ILLINOIS BANCSHARES, INC. .: The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable or such other assets which may be deliverable upon the exercise of the Rights) and requests that certificates for any such shares or securities be issued in the name ofof 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 print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:insert social security or other identifying number: Dated: ______________ __________________, 19______ ________________________________________ Signature Signature Medallion Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (First Mid Illinois Bancshares Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDEFrontier Airlines, INC. Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name ofof and delivered to: Please insert social security or other identifying number:_______________________________ 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 _______________________________ __________________________________________________ _______________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying numberDated:__________ _______________________________________, ____ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:Signature

Appears in 1 contract

Samples: Rights Agreement (Frontier Airlines Inc /Co/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Series B Rights represented by the Right Certificate.) To: OMEGA WORLDWIDEFRUIT OF THE LOOM, INC. The undersigned hereby irrevocably elects to exercise _____________ Series B Rights represented by this Right Series B Rights Certificate to purchase the Preferred Shares issuable upon the exercise of the such Series B Rights (or such other securities of the Corporation Company or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ (Please insert social security or other identifying number) If such number of Series B Rights shall not be all the Series B Rights represented evidenced by this Right Series B Rights Certificate, a new Right Series B Rights Certificate for the balance remaining of such Series B Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number:________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:______________ , 19__ __________________________________________________________________ Signature (Please insert social security or other identifying number) Dated: _________________________, 19__ Signature Guaranteed: Certificate The undersigned hereby certifies __________________________________________________________ Signatures must be guaranteed by checking the appropriate boxes that:an Eligible Guarantor Institution as defined by SEC Rule 17Ad-15 (17 C.F.R. 240.17-Ad-15).

Appears in 1 contract

Samples: Rights Agreement (Fruit of the Loom Inc /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Certificate to purchase the Preferred Shares issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying number:____________________________________________________ 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) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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 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) Date:______________________________________________________________________________ , 19Please insert social security or other identifying number_________________________________ Dated: _______________________ ____________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Daktronics Inc /Sd/)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise __________________ The undersigned hereby irrevocably elects to exercise Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date:________________________________________________________________________________ Please insert social security or other identifying number: _______________________________ Dated: _________________, 19_____ ______________________________ Signature Signature Guaranteed: Certificate ----------- The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (NBT Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDEiPayment, INC. Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the Preferred shares of Series A Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Corporation 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: Please insert social security or other identifying number:____________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Certificate, a new Right 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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: _______________, 200_ , 19__ _______________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Ipayment Inc)

FORM OF ELECTION TO PURCHASE. (To be executed by the registered holder if such holder desires to exercise Rights represented by the Right this Rights Certificate.) ToTO: OMEGA WORLDWIDE, INCST. FRANXXX XXXITAL CORPORATION The undersigned hereby irrevocably elects to exercise __________ Rights represented by this Right Rights Certificate to purchase the Preferred Shares (or other securities, cash or property) issuable upon the exercise of the such Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Preferred Shares be issued in the name of: Please insert social security or other identifying number:print name and address: ______________________________________ ______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please insert social security, taxpayer identification or other identifying number: ______________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Rights Certificate, a new Right Rights Certificate for the balance of such remaining unexercised Rights shall be registered in the name of and delivered to: Please insert social security or other identifying number:print name and address: ______________________________________ ______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please insert social security, taxpayer identification or other identifying number: ______________________________________ (Please print name and address) Date:Dated: __________________ , 19____ ______________________________________ Signature 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. Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:___________________________________________________________

Appears in 1 contract

Samples: Shareholder Rights Agreement (St Francis Capital Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDETo CELL THERAPEUTICS, INC. .: The undersigned hereby irrevocably elects to exercise _________ Rights represented by this Right Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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: Please insert social security or other identifying taxpayer number:: _________________________ __________________________ (Please print name and address) If such number of Rights shall not be all the Rights evidenced by this Right Certificate or if the Rights are being exercised pursuant to Section 11(a)(ii) of the Rights Agreement, a new Right Certificate for the balance of such Rights shall be registered in the name of and delivered to: Please insert social security or other identifying taxpayer number: ____________________________ __________________________ (Please print name and address) Dated: __________, ____ Signature Medallion Signature Guaranteed: _______________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Shareholder Rights Agreement (Cell Therapeutics Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDERAWLINGS SPORTING GOODS COMPANY, INC. .: The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person Person which may be issuable upon the exercise of the Rights) and requests that certificates for such shares be issued in the name ofof and delivered to: Please insert social security or other identifying taxpayer identification number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights represented evidenced by this Right Rights Certificate, a new Right 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 taxpayer identification number:____________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:________________________________________________________________________________ Dated: ______________, 19____ ___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Rawlings Sporting Goods Co Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) To: OMEGA WORLDWIDE, INCCPI CORP. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the Preferred shares of Series A Shares issuable upon the exercise of the Rights (or Common Shares or such other securities of the Corporation 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: Please insert social security or other identifying number:: ________________ ________________________________________________________________________________ (Please print name and address) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented evidenced by this Right Certificate, a new Right 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) ________________________________________________________________________________ ________________________________________________________________________________ (Please print name and address) Date:Dated: ______________ __, 19_200_ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cpi Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Warrant Certificate.) To). TO TALX CORPORATION: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise __________ Rights Warrants represented by this Right Warrant Certificate to purchase the Preferred Shares shares of Common Stock issuable upon the exercise of the Rights (or such other securities of the Corporation or of any other person which may be issuable upon the exercise of the Rights) Warrants and requests that certificates for such shares be issued in the name of: Please insert social security or other identifying number:______________________number ______________________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________ If such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, a new Warrant Certificate for the balance remaining of such Warrants shall be registered in the name of and delivered to: Please insert social security or other identifying number ______________________________ ________________________________________________________________________________ (Please print name and address) Date________________________________________________________________________________ Reference is made to the representations of the Warrant Holder in Section 13 of the Warrant Agreement dated October __, 1996 to which this Warrant relates. By its execution of this election to purchase, the undersigned represents that it has renewed and hereby reaffirms such representations. Dated:______________ __, 19__ __________________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Warrant Agreement (Talx Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, GREATER NEW YORK BANCORP INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof and delivered to: Please insert social security or other identifying number: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: _____________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) Date:______________ , 19__ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Greater New York Bancorp Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDELIBERTY TECHNOLOGIES, INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the Units of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person or other property which may be issuable upon the exercise of the Rights) and requests that certificates for such shares Units be issued in the name ofof 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 represented by this Right Certificate, a new Right 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 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 he registered in the name of and delivered to: _______________________________ (Please print name and address) Date:_______________________________ , 19Please insert social security or other identifying number: _________________ Dated: ______ __, 199_/200_ _____________________________ Signature Signature Guaranteed: 50 Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Liberty Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. TREDEGAR CORPORATION: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation Company or of any other person which that may be issuable upon the exercise of the Rights) and requests that certificates for such shares (or other securities) be issued in the name ofof and delivered to: Please insert social security or other identifying number:____________________________________________________ _________number _______________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:_______________________________________________________________________ _________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) Date:_______________________________________________________________________ Date: _______________, 19____ ___________________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Tredegar Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Rights Certificate.) ToTO: OMEGA WORLDWIDE, WHG RESORTS & CASINOS INC. The undersigned hereby irrevocably elects to exercise ________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation WHG Resorts & Casinos Inc. 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 ofof and delivered to: Please insert social security or other identifying number:____________________________________________________ number ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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:________________________________________________________________________________ If such number of Rights shall not be all 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) Date________________________________________________________________________________ Dated:______________ __________, 19____ ______________________________ Signature Signature Guaranteed: Certificate The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (WHG Resorts & Casinos Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise Rights represented by the Right Certificate.) ToTo Synagro Technologies, Inc.: OMEGA WORLDWIDE, INC. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities or property of the Corporation 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 ofof 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 Right Certificate, a new Right 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:_____________________ ________________________________________________________________________________ (Please print name and address) If such number of Rights shall not be all the Rights represented by this Right Certificate, a new Right 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) DateDated:______________ , 19_______ ________________________________________ Signature Signature Guaranteed: NOTICE The signatures to the foregoing Form of Election To Purchase must correspond to the name as written upon the face of this Right Certificate The undersigned hereby certifies by checking the appropriate boxes that:in every particular, without alteration or enlargement or any change whatsoever.

Appears in 1 contract

Samples: Rights Agreement (Synagro Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if the registered holder desires to exercise Rights represented by the Right Rights Certificate.) To: OMEGA WORLDWIDE, INC. _______________ The undersigned hereby irrevocably elects to exercise __exercise______ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Shares Stock issuable upon the exercise of the Rights (or such other securities of the Corporation 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 ofof 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 represented by this Right Certificate, a new Right 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 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) Date:Please insert social security or other identifying number: ______________________ , 19__ Dated: ____________, ____ __________________________ Signature Signature Guaranteed: Certificate 60 CERTIFICATE The undersigned hereby certifies by checking the appropriate boxes that:

Appears in 1 contract

Samples: Rights Agreement (Cybercash Inc)

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