FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares be issued to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Signature Guaranteed Signature (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any Person acting jointly or in consent with any of the foregoing or any Affiliate or Associate of such Person (as defined in the Rights Agreement). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Glamis Gold LTD)
FORM OF ELECTION TO EXERCISE. (To be exercised by the registered holder if such holder desires to exercise the Rights Certificate.) TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise exercise_____________________________________________________________________________________________________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares or other securities, if applicable, issuable upon the exercise of such Rights and requests that certificates for such Shares securities be issued toin the name of: (NAMEName) (ADDRESSAddress) (CITY AND STATE OR PROVINCECity and Province) Social Insurance Number or other taxpayer identification number. If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAMEName) (ADDRESSAddress) (CITY AND STATE OR PROVINCECity and Province) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Social Insurance Number or other taxpayer identification number. Dated:__________________________________________________________________________________________ Signature Guaranteed Signature Guaranteed: (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever.) Signature must CERTIFICATE (To be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stampcompleted if true) Program. The undersigned party exercising Rights hereunder, hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any a Person acting jointly or in consent concert with any of the foregoing an Acquiring Person or any an Affiliate or Associate of such Person (as defined thereof. Capitalized terms shall have the meaning ascribed thereto in the Rights Shareholder Plan Agreement). Signature
Appears in 1 contract
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTDGTR GROUP INC. The undersigned hereby irrevocably elects to exercise whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares be issued to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Date Signature Guaranteed Signature (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, . without alteration or enlargement or any change whatsoever) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any Person acting jointly or in consent concert with any of the foregoing or any Affiliate or Associate of such Person (as defined in the Rights Agreement). Signature.
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Mad Catz Interactive Inc)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares shares be issued toin the name of: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: Date: __________________________ ________________________________ Signature (NAMEplease print name of signatory) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Signature Guaranteed Signature Guarantee: (Signature must correspond to the name as written upon the face of this the Rights Certificate Certificate, in every particular, without alteration or enlargement enlargement, or any change whatsoever) ). Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company bank or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Programan eligible guarantor institution with membership in an approved signature medallion guarantee program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in consent with any of concert therewith. Capitalized terms shall have the foregoing or any Affiliate or Associate of such Person (as defined meaning ascribed thereto in the Rights Agreement. __________________________________ Signature (please print name of Signatory). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Rubicon Minerals Corp)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTDNEVADA GEOTHERMAL POWER INC. The undersigned hereby irrevocably elects to exercise _______________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares be issued to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will is not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Dated: _______________ Signature Guaranteed Signature (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company bank or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Programan eligible guarantor institution with membership in an approved signature gaurantee medallion program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any Person acting jointly or in consent with any of the foregoing or any Affiliate or Associate of such Person (as defined in the Rights Agreement). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Nevada Geothermal Power Inc)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares shares be issued toin the name of: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) Social Insurance, Social Security or Other Taxpayer Identification Number If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCESocial Insurance, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Social Security or Other Taxpayer Identification Number Date: Signature Guaranteed Signature Guaranteed: (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in consent with any of concert therewith. Capitalized terms shall have the foregoing or any Affiliate or Associate of such Person (as defined meaning ascribed thereto in the Rights Agreement. Signature (please print name of Signatory). Signature
Appears in 1 contract
Sources: Shareholder Protection Rights Plan Agreement (Bakbone Software Inc)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTD. GREAT PANTHER MINING LIMITED The undersigned hereby irrevocably elects to exercise ___________________________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Common Shares be issued to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Signature Guaranteed Signature ______________________________________ (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever.) Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company bank or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stamp) Programan eligible guarantor institution with membership in an approved signature medallion guarantee program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Person, any Affiliate or Associate thereof of such Acquiring Person or any Person acting jointly or in consent concert with the Acquiring Person, or with any Affiliate or Associate of the foregoing Acquiring Person, or any Affiliate or Associate of such Person Persons so acting jointly or in concert (each as defined in the Rights Agreement). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (GREAT PANTHER MINING LTD)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise _______________________________________ whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares shares be issued toin the name of: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Signature Guaranteed Signature Guarantee: (Signature must correspond to the name as written upon the face of this the Rights Certificate Certificate, in every particular, without alteration or enlargement enlargement, or any change whatsoever) ). Signature must be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association an eligible guarantor institution with membership in an approved Medallion (Stamp) Programsignature guarantee program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or by any Person acting jointly or in consent with any of concert therewith. Capitalized terms shall have the foregoing or any Affiliate or Associate of such Person (as defined meaning ascribed thereto in the Rights Agreement. Signature (please print name of Signatory). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Hemisphere Energy Corp)
FORM OF ELECTION TO EXERCISE. TO: GLAMIS GOLD LTDNOVAGOLD RESOURCES INC. The undersigned hereby irrevocably elects to exercise whole Rights represented by the attached Rights Certificate to purchase the Common Shares issuable upon the exercise of such Rights and requests that certificates for such Shares be issued to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAME) (ADDRESS) (CITY AND STATE OR PROVINCE) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Signature Guaranteed Signature (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever) Signature must be guaranteed by a Canadian chartered bank, a major Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association a recognized Medallion (Stamp) Program. The undersigned hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any Person acting jointly or in consent with any of the foregoing or any Affiliate or Associate of such Person (as defined in the Rights Agreement). Signature
Appears in 1 contract
Sources: Shareholder Rights Plan Agreement (Novagold Resources Inc)
FORM OF ELECTION TO EXERCISE. (To be exercised by the registered holder if such holder desires to exercise the Rights Certificate.) TO: GLAMIS GOLD LTD. The undersigned hereby irrevocably elects to exercise whole exercise___________________________________________________________________________________________whole Rights represented by the attached Rights Certificate to purchase the Common Shares or other securities, if applicable, issuable upon the exercise of such Rights and requests that certificates for such Shares securities be issued toin the name of: (NAMEName) (ADDRESSAddress) (CITY AND STATE OR PROVINCECity and Province) Social Insurance Number or other taxpayer identification number. If such number of Rights will shall not be all the Rights evidenced by this Rights Certificate, a new Rights Certificate for the balance of such Rights will shall be registered in the name of and delivered to: (NAMEName) (ADDRESSAddress) (CITY AND STATE OR PROVINCECity and Province) SOCIAL INSURANCE, SOCIAL SECURITY OR OTHER TAXPAYER NUMBER Dated Social Insurance Number or other taxpayer identification number. Signature Guaranteed Signature Guaranteed: (Signature must correspond to name as written upon the face of this Rights Certificate in every particular, without alteration or enlargement or any change whatsoever.) Signature must CERTIFICATE (To be guaranteed by a Canadian chartered bank, a Canadian trust company or a member of a recognized stock exchange or a member of the Transfer Association Medallion (Stampcompleted if true) Program. The undersigned party exercising Rights hereunder, hereby represents, for the benefit of all holders of Rights and Common Shares, that the Rights evidenced by this Rights Certificate are not, and, to the knowledge of the undersigned, have never been, Beneficially Owned by an Acquiring Person or an Affiliate or Associate thereof or any a Person acting jointly or in consent concert with any of the foregoing an Acquiring Person or any an Affiliate or Associate of such Person (as defined thereof. Capitalized terms shall have the meaning ascribed thereto in the Rights Shareholder Plan Agreement). Signature
Appears in 1 contract