SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such 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 this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________
Appears in 2 contracts
Sources: Corporate Advisor / Director Engagement Agreement (Hinto Energy, Inc), Corporate Advisor/Consulting Engagement Agreement (Hinto Energy, Inc)
SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in PartTO BE EXECUTED BY THE WARRANTHOLDER IF HE DESIRES TO EXERCISE THE WARRANT IN WHOLE OR IN PART: To: South Uintah Gas PropertiesSound Advice, Inc. (the "Company") The undersigned undersigned, ___________________________ (Social Security number _____________or taxpayer identification number ___, (Name of Subscriber: Warrantholder) (_________________________________________) (Please insert Social Security or other identifying number of Warrantholder) hereby irrevocably elects to exercise the right of purchase represented by this the within Warrant for, and to purchase thereunder, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company Sound Advice, Inc. in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: ______________:____________________________________________________________ Address: _______________________________________________________________________ _______________________:_________________________________________________________ Deliver to: ______________:______________________________________________________ Address: _______________________________________________________________________ _______________________:_________________________________________________________ and, if such 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 this the within Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Datedbelow: Address:_________________________________________________________ Date:_________________________
Appears in 1 contract
Sources: Warrant Agreement (Sound Advice Inc)
SUBSCRIPTION FORM. To be Executed by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: Part To: South Uintah Gas PropertiesGranite Financial, Inc. (the "Company") The undersigned ___________________________ (Social Security number ______________ Please insert Social Security or taxpayer identification other identifying number of Subscriber: _________________________) _____ hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ______________________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $___________________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: __________________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ Deliver toto : ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such 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 this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: Signature _____________________________________________ Note: The signature on this Subscription Form must correspond with the name as written upon the face of this Warrant in every particular, without alteration or enlargement or any change whatever.
Appears in 1 contract
SUBSCRIPTION FORM. To be Be Executed by the Registered Holder of this Warrant if such Holder Desires in Order to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ________________Registered Holder hereby irrevocably elects to exercise ___________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase Warrants represented by this Warrant forcertificate, and to purchase thereunderthe securities issuable upon the exercise of such Warrants, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock securities shall be issued as follows: Name: __________________________________________________________________________ Address: _________________in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER ______________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ______________________________________________________ [please print or type name and address] and be delivered to ______________________________________________________ and, if such 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 this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________________________________________ ______________________________________________________ ______________________________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. _________________________________________ (Name of NASD Member) Dated: X ___________________________________ ___________________________________ ___________________________________ Address ___________________________________ Taxpayer Identification Number
Appears in 1 contract
Sources: Warrant Purchase Agreement (Bion Environmental Technologies Inc)
SUBSCRIPTION FORM. To be Executed Date: ----------------- iVillage Inc. ▇▇▇-▇▇▇ ▇▇▇ ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇ Attn: President Ladies and Gentlemen: The undersigned hereby elects: / / to exercise the warrant issued to it by the Holder of this Warrant if such Holder Desires to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, iVillage Inc. (the "Company") The undersigned and dated ___________________________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase represented by this Warrant for, and to purchase thereunder, ____________ shares of the Common Stock 2001 (the "Common StockWarrant") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock be issued as follows: Name: ______________________________________________purchase ____________________________ Address: _____________________________________________________________shares of the Common Stock of the Company (the "Shares") purchasable thereunder at a purchase price of $0.01 per Share or an aggregate purchase price of $__________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ________________________________________________________________________________ and, if such number of shares of Common Stock shall not be all (the shares of Common Stock purchasable hereunder, that a new Warrant for "Purchase Price"). Pursuant to the balance remaining terms of the shares of Common Stock purchasable under Warrant the undersigned has delivered the Purchase Price herewith in full in cash or by certified check or wire transfer; or / / to surrender the right to purchase Shares pursuant to this Warrant and to receive in lieu thereof Shares pursuant to the provisions of Section 4 of the Warrant. The undersigned also makes the representations set forth on Attachment B attached to the Warrant. The certificate(s) for such shares shall be registered issued in the name of, and delivered to, of the undersigned at the address stated above. Datedor as otherwise indicated below: ______________________Very truly yours, -------------------------------------------------- (name of holder) By: ------------------------------------------- Name: ------------------------------------------- Title: -------------------------------------------
Appears in 1 contract
SUBSCRIPTION FORM. To be Be Executed by the Registered Holder of this Warrant if such Holder Desires in Order to Exercise this Warrant in Whole or in Part: To: South Uintah Gas Properties, Inc. (the "Company") The undersigned ________________Registered Holder hereby irrevocably elects to exercise ___________ (Social Security number _____________or taxpayer identification number of Subscriber: _________________________) hereby irrevocably elects to exercise the right of purchase Warrants represented by this Warrant forcertificate, and to purchase thereunderthe securities issuable upon the exercise of such Warrants, ____________ shares of the Common Stock (the "Common Stock") provided for therein and tenders payment herewith to the order of the Company in the amount of $______________, such payment being made as provided on the face of this Warrant. The undersigned requests that certificates for such shares of Common Stock securities shall be issued as follows: Name: __________________________________________________________________________ Address: _________________in the name of PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER ______________________________________________________ ________________________________________________________________________________ Deliver to: ____________________________________________________________________ Address: _______________________________________________________________________ ______________________________________________________ [please print or type name and address] and be delivered to ______________________________________________________ and, if such 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 this Warrant be registered in the name of, and delivered to, the undersigned at the address stated above. Dated: ______________________________________________________ ______________________________________________________ ______________________________________________________ [please print or type name and address] and if such number of Warrants shall not be all the Warrants evidenced by this Warrant Certificate, that a new Warrant for the balance of such Warrants be registered in the name of, and delivered to, the Registered Holder at the address stated below. The undersigned represents that the exercise of the within Warrant was solicited by a member of the National Association of Securities Dealers, Inc. If not solicited by an NASD member, please write "unsolicited" in the space below. _________________________________________ (Name of NASD Member) Dated: X ___________________________________ ___________________________________ ___________________________________ Address ___________________________________ Taxpayer Identification Number ___________________________________ Signature Guaranteed
Appears in 1 contract
Sources: Warrant Agreement (Bion Environmental Technologies Inc)