REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 4 contracts
Samples: Warrant Indenture (Columbia Care Inc.), Warrant Indenture (Columbia Care Inc.), Warrant Indenture (Columbia Care Inc.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company the Warrant Agent is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). SCHEDULE “B” TO: Columbia Care Inc. IM Cannabis Corp. (the “CorporationCompany”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 1230, 000 Xxxxxxxxx 0xx Xxxxxx XxxxxxxxxXX, Xxxxxxx Xxxxxxxx Xxxxxxx, XX X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: IM Cannabis Corp. The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 3 contracts
Samples: Warrant Indenture (IM Cannabis Corp.), Warrant Indenture (IM Cannabis Corp.), Warrant Indenture (IM Cannabis Corp.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: ((A) multiplied by $2.95, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 2 contracts
Samples: Warrant Indenture (Columbia Care Inc.), Warrant Indenture (Columbia Care Inc.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey AST Trust Company (Canada) is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. xXxxxx Technologies Corp. (the “"Corporation”") 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey AST Trust Company (the “Warrant Agent”Canada) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire ______________ (A) Common Shares of Columbia Care Inc. Exercise Price Payable: the Corporation) ((A) multiplied by $4.75, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. Any capitalized term in this Warrant Certificate that is not otherwise defined herein, shall have the meaning ascribed thereto in the Warrant Indenture. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 2 contracts
Samples: Warrant Indenture (mCloud Technologies Corp.), Warrant Indenture (mCloud Technologies Corp.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: ((A) multiplied by $5.84, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 2 contracts
Samples: Warrant Indenture (Columbia Care Inc.), Warrant Indenture (Columbia Care Inc.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Chemistree Technology Inc. (the “Corporation”) Suite 810 – 000 Xxxxx XxxxxxXxxxxxxxx Xxxxxx Xxxxxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX Xxxxxxx Xxxxxxxx X0X 0X0 AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Chemistree Technology Inc. Exercise Price Payable: _ ((A) multiplied by $0.70, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 2 contracts
Samples: Warrant Indenture, Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. US IRS regulations, Odyssey Trust Company Computershare is required to request cost basis information from U.S. US securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized butfinalized, rather, but rather the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 0xx Xxxxx, 000 Xxxxx Xxxxxxx Xxxxxx, 00xx Xxxxx Xxx XxxxXxxxxxxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – X0X 0X0 or 000 Xxxxxxxxx Xxxxxx XxxxxxxxxXxxxxxxxxx Xxx., Xxxxxxx Xxxxxxxx 0xx Xxxxx, Xxxxxxx, XX X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice Certificate hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. RENAISSANCE OIL CORP. Exercise Price Payable: ((A) multiplied by $0.50, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified specified in such Warrant Certificate Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):.
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey TSX Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) POET TECHNOLOGIES INC. c/o TSX Trust Company 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxxxxxx Xxxxxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – Xxxxx 000 Xxxxxxxxx Xxxxxx XxxxxxxxxXxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate within Debentures hereby irrevocably elects to convert his or DRS Advice hereby exercises her Debentures of POET Technologies Inc. (the right to acquire "Company") (Aor $ principal amount thereof*) into Common Shares and Warrants of Columbia Care Inc. Exercise the Company at the Conversion Price Payable: The undersigned hereby exercises referred to in the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants attached Debenture Certificate on the terms specified and conditions set forth in such Warrant Certificate certificate and the Indenture. * If less than the full principal amount of the Debentures, indicate in the Warrant Indenturespace provided the principal amount (which must be $1,000 or integral multiples thereof). The undersigned hereby acknowledges that If the undersigned is aware that certificate representing these Debentures contains a U.S. restrictive legend, then the certificates representing the Common Shares received and Warrants underlying these Debentures shall bear the same U.S. restrictive legend on exercise may be subject to restrictions on resale under applicable securities legislationsuch certificates. The undersigned representsOnce completed and executed, warrants and certifies as follows (one (only) of the following this Exercise Form must be checked):mailed or delivered to POET Technologies Inc. c/o TSX Trust Company, 000 Xxxxxxxx Xxxxxx Xxxx, Xxxxx 000, Xxxxxxx, Xxxxxxx X0X 0X0, Attention: Corporation Actions. DATED this ______day of , .
Appears in 1 contract
Samples: Convertible Debenture Indenture (Poet Technologies Inc.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. Trulieve Cannabis Corp. (the “Corporation”) 000 0000 Xxxxxx Xxxxx XxxxxxRoad, 00xx Xxxxx Xxx XxxxTallahassee, XX 00000 XXX FL 32312 AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire __________ (A) Common Subordinate Voting Shares of Columbia Care Inc. Trulieve Cannabis Corp. Exercise Price Payable: __________________________________________________________ ((A) multiplied by CDN$17.25, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Subordinate Voting Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Subordinate Voting Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): ☐ The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: ((A) multiplied by $5.84, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. US IRS regulations, Odyssey Trust Company Computershare is required to request cost basis information from U.S. US securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized butfinalized, rather, but rather the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) Computershare Trust Company of Canada 0xx Xxxxx, 000 Xxxxx Xxxxxxx Xxxxxx, 00xx Xxxxx Xxx XxxxXxxxxxxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – X0X 0X0 or 000 Xxxxxxxxx Xxxxxx XxxxxxxxxXxxxxxxxxx Xxx., Xxxxxxx Xxxxxxxx Xxxxxxx, XX X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire ____________ (A) Common Shares of Columbia Care Inc. RENAISSANCE OIL CORP. Exercise Price Payable: __________________________________________________ ((A) multiplied by $0.20, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. Capitalized terms used but not defined herein have the meanings ascribed to such terms in the warrant indenture dated as of , 2015 between Renaissance Oil Corp. and Computershare Trust Company of Canada. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):): ☐
Appears in 1 contract
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). SCHEDULE "B" EXERCISE FORM TO: Columbia Care Humble & Fume Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx 0000 Xxxxxx Xxxxxx Xxxx, Xxxxx 000 Xxxxxxx, XX 00000 XXX X0X 0X0 AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxxxx Xxxxxx XxxxxxxxxXxxx, Xxxxx 000 Xxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Humble & Fume Inc. Exercise Price Payable: ((A) multiplied by $1.40, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: ((A) multiplied by C$4.53, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). CAN: 30490960.3 TO: Columbia Care Inc. Trulieve Cannabis Corp. (the “Corporation”) 000 0000 Xxxxxx Xxxxx XxxxxxRoad, 00xx Xxxxx Xxx XxxxTallahassee, XX 00000 XXX FL 32312 AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Subordinate Voting Shares of Columbia Care Inc. Trulieve Cannabis Corp. Exercise Price Payable: _ ((A) multiplied by CDN$17.25, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Subordinate Voting Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Subordinate Voting Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): □ The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company the Warrant Agent is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. MPX Bioceutical Corporation (the “Corporation”) 000-000 Xxxxx Xxxxxx0xx Xxxxxx XX, 00xx Xxxxx Xxx XxxxXxxxxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. MPX Bioceutical Corporation Exercise Price Payable: ((A) multiplied by $1.01, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): ☐ The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. US IRS regulations, Odyssey Trust Company AST is required to request cost basis information from U.S. US securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized butfinalized, rather, but rather the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Algernon Pharmaceuticals Inc. (the “"Corporation”") 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey AST Trust Company (the “Warrant Agent”Canada) 323 – 000 Xxxxxxxxx Xxxxxx 1600 - 0000 Xxxx Xxxxxxxx Xx. Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 XX V6E 3X1 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Algernon Pharmaceuticals Inc. Exercise Price Payable: ((A) multiplied by $0.55, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Harvest Health Recreation Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX 1155 W. Rio Salado Parkway Suite 201 Tempe Arizona 85281 AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 400 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire __________ (A) Common Subordinate Voting Shares of Columbia Care Harvest Health Recreation Inc. Exercise Price Payable: __________________________________________________________ ((A) multiplied by CDN$3.05, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Subordinate Voting Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Subordinate Voting Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture (Harvest Health & Recreation Inc.)
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. (the “Corporation”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. Exercise Price Payable: ((A) multiplied by $3.10, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. LEIIO WELLNESS LTD. (the “Corporation”) 000 Xxxxx Xxxxxxc/x Xxxxxxx Xxxxxxx XXX 1400, 00xx Xxxxx 300 – 0xx Xxx XxxxXX Xxxxxxx, XX 00000 XXX X0X 0X0 AND TO: Odyssey Trust Company ODYSSEY TRUST COMPANY (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx1230, Xxxxxxx Xxxxxxxx 300 0xx Xxx. XX Xxxxxxx, XX X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire ____________ (A) Common Shares of Columbia Care Inc. LEIIO WELLNESS LTD. Exercise Price Payable: :_____________________________________________________________________________ The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. Any capitalized term in this Warrant Certificate that is not otherwise defined herein, shall have the meaning ascribed thereto in the Warrant Indenture. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): ☐ The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. US IRS regulations, Odyssey Trust Company is required to request cost basis information from U.S. US securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized butfinalized, rather, but rather the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Marapharm Ventures Inc. (the “CorporationCompany”) 000 Xxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 835 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx XX X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Marapharm Ventures Inc. Exercise Price Payable: ((A) multiplied by $2.90, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
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Samples: Warrant Indenture
REASON FOR TRANSFER – FOR US CITIZENS OR RESIDENTS ONLY. Consistent with U.S. IRS regulations, Odyssey Trust Company the Warrant Agent is required to request cost basis information from U.S. securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized but, rather, the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). TO: Columbia Care Inc. MPX Bioceutical Corporation (the “Corporation”) 000-000 Xxxxx Xxxxxx0xx Xxxxxx XX, 00xx Xxxxx Xxx XxxxXxxxxxx, XX 00000 XXX AND TO: Odyssey Trust Company (the “Warrant Agent”) 323 – 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 The undersigned holder of the Warrants evidenced by this Warrant Certificate or DRS Advice hereby exercises the right to acquire (A) Common Shares of Columbia Care Inc. MPX Bioceutical Corporation Exercise Price Payable: ((A) multiplied by $0.64, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked): ☐ The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
Appears in 1 contract
Samples: Warrant Indenture