Form of Beneficial Owner Election Form

EX-4.10 6 brog_s1a2-ex0410.htm FORM OF BENEFICIAL OWNER ELECTION FORM

Exhibit 4.10

 

BLACK RIDGE OIL & GAS, INC.
 
UP TO 431,819,910 SHARES OF COMMON STOCK
ISSUABLE UPON EXERCISE OF NON-TRANSFERABLE
RIGHTS TO SUBSCRIBE FOR SUCH SHARES
 
BENEFICIAL OWNER ELECTION FORM

 

I (We), the undersigned, acknowledge receipt of your letter and the enclosed materials relating to the offering of shares of common stock, par value $0.001 per share (the “Shares”) of BLACK RIDGE OIL & GAS, INC. (the “Company”), issuable upon the exercise of subscription rights (“Subscription Rights”).

 

In this form, I (we) instruct you whether to exercise Subscription Rights to purchase Shares distributed with respect to the common stock, par value $0.001 per share, of the Company held by you for my (our) account, pursuant to the terms and subject to the conditions set forth in the prospectus dated August 3, 2017 (as amended the “Prospectus”).

 

I (we) hereby instruct you as follows:

 

(CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION)

 

BOX 1.o   Please do not exercise Subscription Rights for me (us).
BOX 2.o   Please exercise Subscription Rights for me (us) and purchase Shares as set forth below:

 

    NUMBER OF SHARES
OF COMMON STOCK		           SUBSCRIPTION
PRICE		         PAYMENT  
Subscription
Right		   ____________________   x     $ _____0.012______   =   $ _________  

 

 

 

    FORM OF PAYMENT:
    o   Payment in the following amount is enclosed: $__________.
    o   Please deduct payment of $__________ from my (our) following account maintained by you:

 

  _________________________________
(Type of Account)		   ________________________________
(Account Number)

 

I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:

 

  • Acknowledge receipt of the Prospectus and irrevocably elect to purchase the number of Shares indicated above upon the terms and conditions specified in the Prospectus; and

 

  • Agree that if I (we) fail to pay for the Shares that I (we) have elected to purchase, you may exercise any remedies available to you under the law.

 

Name of beneficial owner(s):   ____________________________
     
    ____________________________  
     
Signature of beneficial owner(s):   ____________________________
     
    ____________________________
     

 

 

 

   

 

 

If you are signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or in any other fiduciary or representative capacity, please provide the following information:

 

Name:   __________________________________      
         
Capacity:   __________________________________      
         
Address:   __________________________________    
         
    __________________________________    
         
    __________________________________    
         
Telephone No.:   __________________________________