Common use of FORM OF ELECTION TO PURCHASE Clause in Contracts

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 2 contracts

Samples: Rights Agreement (Amerco /Nv/), Rights Agreement (Amerco /Nv/)

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FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOTEKELEC: The undersigned hereby irrevocably elects to exercise ___________________________ Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:________________________________ Address:_____________________________ ___________________________ Social security or taxpayer identification number:__________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:________________________________ Address:_____________________________ ___________________________ Social security or taxpayer identification number:__________________ Dated:________________________, ____ ________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:: Signatures must be guaranteed by a member or a participant in the Securities Transfer Agent Medallion Program, the New York Stock Exchange Medallion Signature Program or the Stock Exchange Medallion Program.

Appears in 2 contracts

Samples: Rights Agreement (Tekelec), Rights Agreement (Tekelec)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Exercise the Right Rights Certificate.) To AMERCOTo: Internet Security Systems, Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social Rights represented by this Rights Certificate to purchase the Junior Preferred Shares issuable upon the exercise of such Rights and requests that certificates for such share(s) be issued in the name: Please insert social security or taxpayer identification number:__________________ other identifying number -------------------------------------------- (Please print name and address) -------------------------------------------- If such number of Rights shall not be all the Rights 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: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ other identifying number -------------------------------------------- (Please print name and address) -------------------------------------------- Dated:__________________ : , --------------- -------- ---------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Rights Certificate) Signature Guaranteed:)

Appears in 2 contracts

Samples: Rights Agreement (Internet Security Systems Inc/Ga), Rights Agreement (Internet Security Systems Inc/Ga)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOOwens Corning: The undersigned hereby irrevocably herexx xxrevocably elects to exercise exer cise _______________ Rights represented by this Right Certificate Cer tificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates certifi cates for such shares be issued in the name of: Name:Xxease insert social security or other identifying number __________________________________________________________ Address:__________________ (Please print name and address) _____________________ Social security or taxpayer identification number:______________________________________ If such number of Rights shall not be all the Rights evidenced 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: Name:Please insert social security or other identifying number __________________________________________________________ Address:__________________ (Please print name and address) _____________________ Social security or taxpayer identification number:______________________________________ Dated:__________________, ____ [Form of Election to Purchase -- continued] __________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:.)

Appears in 2 contracts

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

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise the Right Certificate.) To AMERCOTo: The Enstar Group, Inc. The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares share(s) be issued in the name ofname: Name:___________________________________________________________ Address:(Please print name and address) __________________ __________________________________________ Social (Please insert social security or taxpayer identification 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: Name:Please insert social security or other identifying number ____________________________________________ Address:(Please print name and address) Dated: ________________, 19__ _____________________ Social security or taxpayer identification number:________________________ Dated:__________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Enstar Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOThe Goodyear Tire & Rubber Company: The undersigned hereby irrevocably elects to exercise ____________ ---------------- Rights represented by this Right Certificate to purchase the shares of Preferred the Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ 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: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ other identifying number ------------------------------------------------------------------------------- Dated:__________________ : , 19 ---------------- ---- ----------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Goodyear Tire & Rubber Co /Oh/)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Exercise the Right Certificate.) To AMERCOTo: Resource Bancshares Mortgage Group, Inc. The undersigned hereby irrevocably elects to exercise ____________________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares share(s) be issued in the name ofname: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ 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: Name:Please insert social security or other identifying number -------------------------------------------- Dated: _________________, ____ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ ---------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:)

Appears in 1 contract

Samples: Rights Agreement (Resource Bancshares Mortgage Group Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO: GRC International, Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates certifies for such shares be issued in the name of: Name:Please insert social security or other identifying number (Please print name and address) _____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:Please insert social security Or other identifying number (Please print name and address) _______________________________________ AddressDated:_________________________________ _____________________ Social security or taxpayer identification number:___________________ Dated:__________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:)

Appears in 1 contract

Samples: Rights Agreement (GRC International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOArch Coal, Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:___________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ __________________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:: Signatures must be guaranteed by a member or a participant in the Securities Transfer Agent Medallion Program, the New York Stock Exchange Medallion Signature Program or the Stock Exchange Medallion Program.

Appears in 1 contract

Samples: Rights Agreement (Arch Coal Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCONew Ralcorp Holdings, Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_: ____________________ Address:___________________ _____________________ Social security or taxpayer identification number:___________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_: ____________________ Address:_: _________________ _____________________ Social security or taxpayer identification number:___________________ Dated:___________ , 19 _________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:: Signatures must be guaranteed by a member firm of a registered 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.

Appears in 1 contract

Samples: Shareholder Protection Rights Agreement (New Ralcorp Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOthe Company and the Rights Agent: The undersigned hereby irrevocably elects to exercise _____________________ Rights represented by this Right Certificate and to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:Please insert social security or other identifying number: _____________________ Address:__________________ ________________________________________________________________________________ Social security or taxpayer identification 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: Name:Please insert social security or other identifying number: _____________________ Address:__________________ ________________________________________________________________________________ Social security or taxpayer identification number:(Please print name and address) ________________________________________________________________________________ Dated:: _________________ ___________________________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:)

Appears in 1 contract

Samples: Rights Agreement (Online Power Supply Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOthe Company and the Rights Agent: The undersigned hereby irrevocably elects to exercise _________________ Rights represented by this Right Certificate and to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________Please insert social security or other identifying number: ________ _____________________ Social security or taxpayer identification 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: Name:_____________________ Address:_____Please insert social security or other identifying number: _____________ _____________________ Social security or taxpayer identification number:(Please print name and address) Dated: ______________, ____ Dated:__________________ Signature: (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (International Rectifier Corp /De/)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOFURNITURE BRANDS INTERNATIONAL, INC.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ ___________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

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 AMERCOTo: PINNACLE HOLDINGS INC. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Preferred Stock (or Common Stock or such other securities of the Company or any other Person) issuable upon the exercise of such the Rights and requests that certificates for such shares be issued in the name ofof and delivered to: Name:Please insert social security or other identifying number _____________________ Address:__________________ ________________________________________________________________________________ Social security or taxpayer identification number:(Please print name and address) ________________________________________________________________________________ If such number of Rights shall not be all the Rights evidenced represented 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: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ (Signature must conform in all respects to name Form of holder as specified on the face Reverse Side of this Right Certificate) Signature Guaranteed:Rights Certificate - continued

Appears in 1 contract

Samples: Rights Agreement (Pinnacle Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCODHB INDUSTRIES, INC.: The undersigned hereby irrevocably elects to exercise ____________ _____Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name: Address:_____________________ Address:__________________ _____________________________ Social security or taxpayer identification number:______________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name: Address:_____________________ Address:__________________ _____________________________ Social security or taxpayer identification number:______________________________ Dated:: _______________________________ ______________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (DHB Industries Inc)

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FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO[NAME OF COMPANY]: The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:: _________________________________ Address:: __________________ _____________________ Social security Security or taxpayer identification number:: ______________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:: ______________________________ Address:_____________________________ Social Security or taxpayer identification number: _____________________________ Social security or taxpayer identification number:Dated: __________________ Dated:__________________ (Signature must conform in all respects respect to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Energizer Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOSCS TRANSPORTATION, INC.: The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ : --------------------------- Address:__________________ _____________________ : --------------------------- --------------------------- Social security or taxpayer identification number:__________________ : ------------------------------------ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ : --------------------------- Address:__________________ _____________________ : --------------------------- --------------------------- Social security or taxpayer identification number:__________________ : ------------------------------------ Dated:__________________ : ---------------- Signature ---------------------------------- (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (SCS Transportation Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if registered holder desires to exercise Exercise the Right Rights Certificate.) To AMERCOTo: Z-Tel Technologies, Inc. The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Rights Certificate to purchase the shares of Junior Preferred Stock Shares issuable upon the exercise of such Rights and requests that certificates for such shares share(s) be issued in the name ofname: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ other identifying number -------------------------------------------- (Please print name and address) -------------------------------------------- If such number of Rights shall not be all the Rights 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: Name:Please insert social security or other identifying number -------------------------------------------- (Please print name and address) -------------------------------------------- Dated: _________________, ____ Address:__________________ _____________________ Social security or taxpayer identification number:__________________ Dated:__________________ ---------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Rights Certificate) Signature Guaranteed:)

Appears in 1 contract

Samples: Rights Agreement (Z Tel Technologies Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOESCO Electronics Corporation: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ : --------------------- Address:__________________ _____________________ : ------------------ --------------------- Social security or taxpayer identification number:__________________ : -------------------- If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ : ---------------------- Address:__________________ _____________________ : ------------------- ---------------------- Social security or taxpayer identification number:__________________ : --------------------- Dated:__________________ : ------------------- -------------------------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Esco Electronics Corp)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO: GRC International, Inc. The undersigned hereby irrevocably elects to exercise ____________ ------- Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates certifies for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ 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: Name:_____________________ Address:__________________ _____________________ Social Please insert social security or taxpayer identification number:__________________ other identifying number ------------------------------------- (Please print name and address) ------------------------------------- Dated:__________________ : ------------------------------- ------------------------------------- Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:)

Appears in 1 contract

Samples: Rights Agreement (GRC International Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOWorldCom, Inc.: The undersigned hereby irrevocably elects to exercise _____________________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:: ____________________________________________ Address:: ____________________________________________ ____________________________________________ Social security or taxpayer identification number:: _______________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:: ____________________________________________ Address:: ____________________________________________ ____________________________________________ Social security or taxpayer identification number:: _______________________________ Dated:: ________________ ____________________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Worldcom Inc/ga//)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCO[NAME OF COMPANY]: The undersigned hereby irrevocably elects to exercise _____________ Rights represented by this Right Certificate to purchase the shares of Preferred Stock Common Shares issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:: _________________________________ Address:: __________________ _____________________ Social security Security or taxpayer identification number:: ______________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:: ______________________________ Address:_____________________________ Social Security or taxpayer identification number: _____________________________ Social security or taxpayer identification number:Dated: __________________ Dated:__________________ (Signature must conform in all respects respect to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:: Signatures must be guaranteed by a member or a participant in the Securities Transfer Agent Medallion Program, the New York Stock Exchange Medallion Signature Program or the Stock Exchange Medallion Program.

Appears in 1 contract

Samples: Rights Agreement (Energizer Holdings Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOXxxxxx Industries, Inc.: The undersigned hereby irrevocably elects to exercise ____________ Rights represented by this Right Certificate to purchase the shares of Preferred Common Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:___________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:_____________________ Address:__________________ _____________________ Social security or taxpayer identification number:___________________ Dated:__________________ (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:: Signatures must be guaranteed by a member or a participant in the Securities Transfer Agent Medallion Program, the New York Stock Exchange Medallion Signature Program or the Stock Exchange Medallion Program.

Appears in 1 contract

Samples: Rights Agreement (Harmon Industries Inc)

FORM OF ELECTION TO PURCHASE. (To be executed if holder desires to exercise the Right Certificate.) To AMERCOVISTACARE, INC.: The undersigned hereby irrevocably elects to exercise ____________ _____Rights represented by this Right Certificate to purchase the shares of Preferred Stock issuable upon the exercise of such Rights and requests that certificates for such shares be issued in the name of: Name:: ____________________________ Address:: _________________________ _____________________________ Social security or taxpayer identification number:: __________________________ If such number of Rights shall not be all the Rights evidenced by this Right Certificate, a new Right Certificate for the balance remaining of such Rights shall be registered in the name of and delivered to: Name:: ____________________________ Address:: _________________________ _____________________________ Social security or taxpayer identification number:: __________________________ Dated:: ___________ _______________________________ Signature (Signature must conform in all respects to name of holder as specified on the face of this Right Certificate) Signature Guaranteed:

Appears in 1 contract

Samples: Rights Agreement (Vistacare, Inc.)

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