NUMBER SHARES
EX-4.1 2 v18534exv4w1.htm EX-4.1 exv4w1
Exhibit 4.1
NUMBER | SHARES |
HY
COMMON STOCK | HYTHIAM, INC. INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE | SEE REVERSE FOR CERTAIN DEFINITIONS AND LEGENDS CUSIP 44919F 10 4 |
THIS CERTIFIES THAT
IS THE OWNER OF
FULLY PAID AND NON-ASSESSABLE SHARES OF THE PAR VALUE: $.0001 PER SHARE OF THE COMMON STOCK OF
HYTHIAM, INC.
transferable on the books of the corporation 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 the provisions of the law of the State of Delaware and to all of the provisions of the Certificate of Incorporation and the Bylaws of the Corporation as amended from time to time (copies of which are on file at the office of the Corporation) all of which the holder of this certificate by acceptance hereof assents. This certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar.
IN WITNESS WHEREOF the said Corporation has caused this certificate to be signed by its duly authorized officers and its corporate seal to be hereinto affixed.
COUNTERSIGNED AND REGISTERED: AMERICAN STOCK TRANSFER & TRUST COMPANY | ||||
TRANSFER AGENT | ||||
AND REGISTRAR | ||||
By | ||||
AUTHORIZED SIGNATURE | ||||
SECRETARY | [SEAL] | CHAIRMAN AND CHIEF EXECUTIVE OFFICER | ||
HYTHIAM, INC.
THE CORPORATION WILL FURNISH WITHOUT CHARGE TO EACH STOCKHOLDER WHO SO REQUESTS A STATEMENT OF THE POWERS, DESIGNATIONS, PREFERENCES AND RELATIVE, PARTICIPATING, OPTIONAL OR OTHER SPECIAL RIGHTS OF EACH CLASS OF STOCK OR SERIES THEREOF OF THE CORPORATION, AND THE QUALIFICATIONS, LIMITATIONS OR RESTRICTIONS OF SUCH PREFERENCES AND/OR RIGHTS. SUCH REQUEST MAY BE MADE TO THE CORPORATION OR THE TRANSFER AGENT.
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 | ||||||||||
TEN ENT | | as tenants by the entireties | (Cust) | (Minor) | ||||||||||
JT TEN | | as joint tenants with right of survivorship and not as tenants in common | Under Uniform Gifts to Minors Act | |||||||||||
(State) |
Additional abbreviations may also be used though not in the above list
For Value Received, _____________________________________________________ hereby sell(s), assign(s) and transfer(s) unto |
PLEASE INSERT SOCIAL SECURITY
OR OTHER IDENTIFYING
NUMBER OF ASSIGNEE
OR OTHER IDENTIFYING
NUMBER OF ASSIGNEE
(PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)
Shares | ||
of the capital stock represented by the within certificate, and do(es) hereby irrevocably constitute and appoint
Attorney to | ||
transfer the said stock on the books of the within-named Corporation with full power of substitution in the premises.
Dated | ||||||||
SIGNATURE OF REGISTERED OWNER(S) | ||||||||
X | ||||||||
(SIGNATURE) | ||||||||
X | ||||||||
(SIGNATURE) | ||||||||
NOTICE | THE SIGNATURE(S) TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) OF THE REGISTERED OWNERS AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER. | |||||||
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 RULE 17Ad-15 UNDER THE SECURITIES EXCHANGE ACT OF 1934. | ||||||||
SIGNATURE(S) GUARANTEED BY: |