PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER OF ASSIGNEE

EX-4.1 3 d615962dex41.htm EX-4.1 EX-4.1

Exhibit 4.1

 

ZQ|CERT#|COY|CLS|RGSTRY|ACCT#|TRANSTYPE|RUN#|TRANS#
COMMON STOCK PAR VALUE $0.001 Agtc COMMON STOCK THIS CERTIFICATE IS TRANSFERABLE IN CANTON, MA, JERSEY CITY, NJ AND COLLEGE STATION, TX
Certificate Number ZQ00000000 APPLIED GENETIC TECHNOLOGIES CORPORATION INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE Shares
**000000 ******************
***000000*****************
****000000****************
*****000000***************
******000000**************
THIS CERTIFIES THAT is the owner of
MR. SAMPLE & MRS. SAMPLE & MR. SAMPLE & MRS. SAMPLE
***ZERO HUNDRED THOUSAND ZERO HUNDRED AND ZERO***
CUSIP 03820J 10 0
SEE REVERSE FOR CERTAIN DEFINITIONS
FULLY-PAID AND NON-ASSESSABLE SHARES OF COMMON STOCK OF
Applied Genetic Technologies Corporation (hereinafter called the “Company”), transferable on the books of the Company in person or by duly authorized attorney, upon surrender of this Certificate properly endorsed. This Certificate and the shares represented hereby, are issued and shall be held subject to all of the provisions of the Certificate of Incorporation, as amended, and the By-Laws, as amended, of the Company (copies of which are on file with the Company and with the Transfer Agent), to all of which each holder, by acceptance hereof, assents. This Certificate is not valid unless countersigned and registered by the Transfer Agent and Registrar.
Witness the facsimile seal of the Company and the facsimile signatures of its duly authorized officers.
FACSIMILE SIGNATURE TO COME President
FACSIMILE SIGNATURE TO COME Secretary
Applied Genetic Technologies Corporation SEAL 2003 DELAWARE
DATED DD-MMM-YYYY
COUNTERSIGNED AND REGISTERED: COMPUTERSHARE TRUST COMPANY, N.A. TRANSFER AGENT AND REGISTRAR,
By AUTHORIZED SIGNATURE
SECURITY INSTRUCTIONS ON REVERSE 1234567

 

APPLIED GENETIC TECHNOLOGIES CORPORATION

THE COMPANY WILL FURNISH WITHOUT CHARGE TO EACH SHAREHOLDER WHO SO REQUESTS, A SUMMARY OF THE POWERS, DESIGNATIONS, PREFERENCES AND RELATIVE, PARTICIPATING, OPTIONAL OR OTHER SPECIAL RIGHTS OF EACH CLASS OF STOCK OF THE COMPANY AND THE QUALIFICATIONS, LIMITATIONS OR RESTRICTIONS OF SUCH PREFERENCES AND RIGHTS, AND THE VARIATIONS IN RIGHTS, PREFERENCES AND LIMITATIONS DETERMINED FOR EACH SERIES, WHICH ARE FIXED BY THE CERTIFICATE OF INCORPORATION OF THE COMPANY, AS AMENDED, AND THE RESOLUTIONS OF THE BOARD OF DIRECTORS OF THE COMPANY, AND THE AUTHORITY OF THE BOARD OF DIRECTORS TO DETERMINE VARIATIONS FOR FUTURE SERIES. SUCH REQUEST MAY BE MADE TO THE OFFICE OF THE SECRETARY OF THE COMPANY OR TO THE TRANSFER AGENT. THE BOARD OF DIRECTORS MAY REQUIRE THE OWNER OF A LOST OR DESTROYED STOCK CERTIFICATE, OR HIS LEGAL REPRESENTATIVES, TO GIVE THE COMPANY A BOND TO INDEMNIFY IT AND ITS TRANSFER AGENTS AND REGISTRARS AGAINST ANY CLAIM THAT MAY BE MADE AGAINST THEM ON ACCOUNT OF THE ALLEGED LOSS OR DESTRUCTION OF ANY SUCH CERTIFICATE HELD BY SUCH PERSON OR ANY SUBSEQUENT HOLDER, SHALL BECOME NULL AND VOID.

 

 

The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations:

 

    TEN COM   -   as tenants in common   UNIF GIFT MIN ACT -  

 

   Custodian  

 

    
          (Cust)     (Minor)    
    TEN ENT   -   as tenants by the entireties     under Uniform Gifts to Minors Act  

 

    
              (State)    
    JT TEN   -   as joint tenants with right of survivorship and not as tenants in common   UNIF TRF MIN ACT   -  

 

   Custodian (until age  

 

   )
          (Cust)          
         

 

   under Uniform Transfers to Minors Act  

 

    
          (Minor)     (State)    

 

Additional abbreviations may also be used though not in the above list.

 

    

 

 

PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING      

NUMBER OF ASSIGNEE          

 

For value received,                                          hereby sell, assign and transfer unto

 

    

 

(PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)

 

 

 

    Shares
of the common 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 Company with full power of substitution in the premises.   

 

Dated:  

 

    20   

 

Signature:  

 

Signature:  

 

  Notice:    The signature to 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.

Signature(s) Guaranteed: Medallion Guarantee Stamp

THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (Banks, Stockbrokers, Savings and Loan Associations and Credit Unions) WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM, PURSUANT TO S.E.C. RULE 17Ad-15.