Please issue a certificate or certificates representing said ______ shares in the name of the undersigned or in such other name or names as are specified below: -------------------------------- (Name) -------------------------------- (Address)
Please issue a certificate or certificates representing said shares in the name of the undersigned or in such other name or names as are specified below: Name: Address:
Please issue a certificate or certificates representing said shares of stock in the name of the undersigned or in such other name as is specified below: ____________________________ (Name) ____________________________ (Address) ____________________________
Please issue a certificate representing the shares of Common Stock in the name of the Holder or in such other name as is specified below:
Please issue a certificate or certificates representing said shares of Warrant Stock in the name of the undersigned or in such other name as is specified below: ---------------------------------------- (Name) ---------------------------------------- (Address) ------------------------- ---------------------------------------- (Date) (Name of Warrant Holder) By: ------------------------------------ Title: ---------------------------------- Attachment 2 INVESTMENT REPRESENTATION STATEMENT Shares of the Securities (as defined in the attached Warrant) of TELOCITY, INC. In connection with the purchase of the above-listed securities, the undersigned hereby represents to Telocity, Inc. (the "Company") as follows:
(a) The securities to be received upon the exercise of the Warrant (the "Securities") will be acquired for investment for its own account, not as a nominee or agent, and not with a view to the sale or distribution of any part thereof, and the undersigned has no present intention of selling, granting participation in or otherwise distributing the same, but subject, nevertheless, to any requirement of law that the disposition of its property shall at all times be within its control. By executing this Statement, the undersigned further represents that it does not have any contract, undertaking, agreement or arrangement with any person to sell, transfer, or grant participations to such person or to any third person, with respect to any Securities issuable upon exercise of the Warrant.
(b) The undersigned understands that the Securities issuable upon exercise of the Warrant at the time of issuance may not be registered under the Securities Act of 1933, as amended (the "Act"), and applicable state securities laws, on the ground that the issuance of such securities is exempt pursuant to Section 4(2) of the Act and state law exemptions relating to offers and sales not by means of a public offering, and that the Company's reliance on such exemptions is predicated on the undersigned's representations set forth herein.
(c) Except for a transfer by the undersigned, in the event the undersigned is a partnership, to a limited or general partner of such partnership, the undersigned agrees that in no event will it make a disposition of any Securities acquired upon the exercise of the Warrant unless and until (i) it shall have notified the Company of the proposed disposition, and (ii) it shall have furnished the Company with an opinion of counsel reasonably satisfactory to the Company a...
Please issue a certificate representing the Warrant Shares in the name of the Holder and deliver the certificate to the address set forth below.
Please issue a certificate representing the shares of the Preferred Stock in the name of the Holder or in such other name as is specified below: Names: Address:
Taxpayer I. D.:
Please issue a certificate or certificates representing said shares of the Common Stock in the name of the undersigned or in such other name as is specified below:
Please issue a certificate or certificates representing said shares in the name of the undersigned or in such other name as is specified below: ------------------------ (Name) ------------------------ ------------------------ ------------------------ (Address) and, if such shares of Common Stock shall not include all of the shares of Common Stock issuable as provided in this Warrant, that a new Warrant of like tenor and date for the balance of the shares of Common Stock issuable hereunder be delivered to the undersigned. (Delete following paragraph if not applicable:) [Holder hereby represents to you that it has sold or has current plans to resell all of such Common Shares received upon this exercise of this Warrant, solely in accordance with the terms of the Registration Statement filed with the U.S. Securities and Exchange Commission by the Company covering such Common Shares as described under the section entitled "Plan of Distribution" therein.] ------------------------------------- (Name of Registered Owner) ------------------------------------- (Signature of Registered Owner) ------------------------------------- (Street Address) ------------------------------------- (State) (Zip Code) NOTICE: The signature on this subscription must correspond with the name as written upon the face of the Warrant in every particular, without alteration or enlargement or any change whatsoever. EXHIBIT B ASSIGNMENT FORM FOR VALUE RECEIVED the undersigned registered owner of this Warrant for the purchase of shares of common stock of NexMed, Inc. hereby sells, assigns and transfers unto the Assignee named below all of the rights of the undersigned under this Warrant, with respect to the number of shares of common stock set forth below: --------------------------------------- --------------------------------------- --------------------------------------- (Name and Address of Assignee) --------------------------------------- (Number of Shares of Common Stock) and does hereby irrevocably constitute and appoint ____________ attorney-in-fact to register such transfer on the books of the Company, maintained for the purpose, with full power of substitution in the premises. Dated:_________________________________ -------------------------------------- (Print Name and Title) -------------------------------------- (Signature) -------------------------------------- (Witness)
Please issue a certificate or certificates representing said shares of the Common Stock in the name of the undersigned or in such other name as is specified below.
