Common use of PURCHASE FORM Clause in Contracts

PURCHASE FORM. To: __________________ __________________ __________________ The undersigned pursuant to the provisions set forth in the attached Warrant, hereby irrevocably elects to purchase ___________ shares of the Common Stock (the "Common Stock") covered by such Warrant and herewith makes payment of $_______, representing the full purchase price for such shares at the price per share provided for in such Warrant. The undersigned understands and acknowledges the terms and restrictions on the right to transfer or dispose of the Common Stock set forth in Section 6 of the attached Warrant, which the undersigned has carefully reviewed. The undersigned consents to the placing of a legend on its certificate for the Common Stock referring to such restrictions and the placing of stop transfer orders until the Common Stock may be transferred in accordance with the terms of such restrictions. By:_________________________________ Name:_______________________________ Title:______________________________ Date:_______________________________ ANNEX C METHOD FOR DETERMINING PRIVATE VALUATION OF ISSUER