Common use of PURCHASE FORM Clause in Contracts

PURCHASE FORM. To: Mayor’s Jewelers, Inc. The undersigned irrevocably exercises the Warrant for the purchase of shares (subject to adjustment) of Common Stock of Mayor’s Jewelers, Inc., for the Warrant and herewith makes payment of $ (the “Exercise Price”) through the following method: • such payment of the Exercise Price being in cash or by certified or official bank check payable to the order of Mayor’s Jewelers, Inc. or • such payment of the Exercise Price made by surrendering of such additional part of the Warrant having an aggregate Spread (as such term is defined in the Warrant Agreement) equal to the aggregate Exercise Price, all at the Exercise Price and on the terms and conditions specified in the within the Warrant Agreement therein referred to, surrenders the Warrant and all right, title and interest therein to Mayor’s Jewelers, Inc. and directs (subject to Section 9 of the Warrant Agreement) that the shares of Common Stock deliverable upon the exercise of such Warrant be registered or placed in the name and at the address specified below and delivered thereto. The undersigned hereby certifies to Mayor’s Jewelers, Inc. that it is, at the time of exercise of the Warrant, an “accredited investor” as defined in Rule 501(a) of the Securities Act of 1933, as amended. Date: , (Signature of Owner)1 (Street Address) (City) (State) (Zip Code) Securities and/or check to be issued to: Please insert social security or identifying number: Name: Street Address: City, State and Zip Code: