To Be Executed. Upon Exercise of Warrant The undersigned hereby irrevocably elects to exercise Warrants evidenced by this Warrant Certificate, to purchase _________ (currency) principal amount of the [Title of Warrant Securities] (the "Warrant Securities") of Alexander & Alexander Services Inc. and represents that he has tendered payment for such Warrant Securities [in cash or by certified check or official bank check or by bank wire transfer, in each case] [by bank wire transfer], in immediately available funds, to the order of Alexander & Alexander Services Inc., c/o [insert name and address of Warrant Agent], in the amount of _________ (currency) in accordance with the terms hereof. The undersigned requests that said principal amount of Warrant Securities be in fully registered form and in the authorized denominations, registered in such names and delivered, all as specified in accordance with the instructions set forth below. If the number of Warrants exercised is less than all of the Warrants evidenced hereby, the undersigned requests that a new Warrant Certificate representing the remaining Warrants evidenced hereby be issued and delivered to the undersigned unless otherwise specified in the instructions below. Dated: Name ________________________ (Please Print) _________________________ Address ______________________ Social Security Number or ______________________ Other Identifying Number of ______________________ Holder Signature _____________________ The Warrants evidenced hereby may be exercised at the following addresses: By hand at ____________________________________________ -------------------------------------------- -------------------------------------------- By mail at ____________________________________________ -------------------------------------------- -------------------------------------------- [Instructions as to form and delivery of Warrant Securities and, if applicable, Warrant Certificates evidencing unexercised Warrants -- complete as appropriate.]
To Be Executed. By The Warrantholder If He Desires To Exercise The Warrant In Whole Or In Part: To: The undersigned, ____________________________, (Name of Warrantholder) (____________________________________________) (Please insert Social Security or other identifying number of subscriber) hereby irrevocably elects or exercises the right of purchase represented by the within Warrant for, and to purchase thereunder, __________ shares of Common Stock provided for therein and tenders payment herewith to the order of Alliance Pharmaceutical Corp. in the amount $__________. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: Address: Deliver to: Address: and, if said number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under the within Warrant be registered in the name of, and delivered to, the undersigned at the address states below: Address: Date:
To Be Executed. On Or After The Effective Date)
To Be Executed. BY OPTIONEE IF IT DESIRES TO EXERCISE THE WITHIN OPTION
To Be Executed. By The Warrant Holder If He Desires To Exercise The Warrant In Whole Or In Part: To: Square Industries, Inc. The undersigned (_________________________________) Please insert Social Security or other identifying number of Subscriber hereby irrevocably elects to exercise the right of purchase represented by the within warrant for, and to purchase thereunder, shares of Common Stock provided for therein and tenders payment herewith to the order of Square Industries, Inc. in the amount of $ and, if said number of shares of Common Stock shall not be all the shares of Common Stock purchasable hereunder, that a new Warrant for the balance remaining of the shares of Common Stock purchasable under the within Warrant be registered in the name of, and delivered to, the undersigned at the address stated below: Address: _________________________________________ Date: _____________
To Be Executed. By The Warrantholder If He Desires
To Be Executed. BY PRINCIPAL Signed, sealed, and delivered in the presence of: Witness Signature of Principal Printed Name of Individual Address Witness Address When Principal is a Sole Proprietorship or Operates under a Trade Name Witness Signature of Proprietor/Signer Printed Name of Proprietor/Signer Address Witness Address Witness Name of Partnership By: (Seal) Address Signature of Partner Witness Printed Name of Partner Address When Principal is a Corporation: Attest: By (Affix Corporate Seal) Printed Name & Official Title Certificate as to Corporate Principal: I , certify that I am the Secretary of the corporation named as Principal in the within bond; that , who signed the said bond on behalf of the Principal was then of said corporation: that I know his/her signature, and her/his signature thereto is genuine; and that said Xxxx was duly signed, sealed and attested for an on behalf of Said corporation by authority of its governing body. Secretary (SEAL) STATE OF FLORIDA ) COUNTY OF ) The foregoing instrument was acknowledged before me this day of , by
To Be Executed. By The Warrant Holder Who Desires To Exercise The Warrant In Whole Or In Part: To: MEDIS TECHNOLOGIES LTD. The undersigned............................................
