1
SEE REVERSE SIDE FOR RESTRICTIONS
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INCORPORATED UNDER THE LAWS OF DELAWARE
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No. Specimen [ART: EAGLE ON GLOBE] XXX Shares
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SELFCARE, INC.
FULLY-PAID AND NON-ASSESSABLE SHARES OF
SERIES A CONVERTIBLE PREFERRED STOCK
$.001 PAR VALUE
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THIS
CERTIFIES
THAT Specimen is the owner of
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XXX (XXX) ---------------Shares of the Stock of
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SELFCARE, INC. Series A Convertible Preferred
transferable only on the books of the Corporation by the holder hereof in
person or by Attorney upon surrender of this Certificate properly endorsed.
IN WITNESS WHEREOF, the said Corporation has caused this Certificate
to be signed by its duly authorized officers and its Corporate Seal to
be hereunder affixed this__________day of________________A.D. __
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President and Chief Executive Officer Secretary
SHARES $.001 par value EACH
[Copyright] GOES 196
FORM 196P H.& W., INC.
SELFCARE, INC.
Fully-paid and non-assessable shares of
Series A Convertible Preferred Stock
$.001 par value PREFERRED
CERTIFICATE
NO.196.
NO. Specimen
For XXX Shares
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Issued to
Specimen
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Dated
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FROM WHOM TRANSFERRED
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Dated
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NO. ORIGINAL NO. ORIGINAL NO. OF SHARES
CERTIFICATE SHARES TRANSFERRED
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Received CERTIFICATE NO. Specimen
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For XXX Shares
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this day of
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FORM 196P XXXXX & XXXXXX, INC.
2
The Issuer is authorized to issue more than one class of stock. The Issuer will
furnish without charge to each stockholder who requests a copy of the powers,
designations, preferences and relative, participating, optional, or other
special rights of each outstanding class of stock or series thereof of the
Issuer, and the qualifications, limitations or restrictions of such preferences
and/or rights.
The shares of the Issuer represented by this certificate have been issued
pursuant to Regulation S promulgated under the Securities Act of 1933, as
amended ("Act"), and have not been registered under the Act. These shares may
not be offered or sold within the United States or to or for the account of a
"U.S. Person" (as that term is defined in Regulation S) until after the fortieth
(40th) day following completion of the Regulation S offering of the Issuer
pursuant to which these shares have been issued and only in compliance with the
Act. The Issuer will notify the transfer agent of the date of completion of such
offering.
The Issuer is authorized to issue more than one class of stock. The Issuer will
furnish without charge to each stockholder who requests a copy of the powers,
designations, preferences and relative, participating, optional, or other
special rights of each outstanding class of stock or series thereof of the
Issuer, and the qualifications, limitations or restrictions of such preferences
and/or rights.
The shares of the Issuer represented by this certificate have been issued
pursuant to Regulation S promulgated under the Securities Act of 1933, as
amended ("Act"), and have not been registered under the Act. These shares may
not be offered or sold within the United States or to or for the account of a
"U.S. Person" (as that term is defined in Regulation S) until after the fortieth
(40th) day following completion of the Regulation S offering of the Issuer
pursuant to which these shares have been issued and only in compliance with the
Act. The Issuer will notify the transfer agent of the date of completion of such
offering.
CERTIFICATE
FOR
XXX
SHARES
of the
STOCK
Series A Convertible Preferred
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SELFCARE, INC.
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ISSUED TO
Specimen
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DATE
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For Value Received,______hereby sell, assign and transfer
unto____________________________________
______________________________________________Shares of the Stock represented by
the within Certificate, and do hereby irrevocably constitute and appoint
___________________________________________________Attorney to transfer the said
Stock on the books of the within named Corporation with full power of
substitution in the premises.
Dated_______________________ _____
In presence of _____________________________________
_______________________________________
NOTICE. THE SIGNATURE OF THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME AS
WRITTEN UPON THE FACE OF THE CERTIFICATE, IN EVERY PARTICULAR, WITHOUT
ALTERATION OR ENLARGEMENT, OR ANY CHANGE WHATEVER.
