DELIVERY OPTIONS FOR SUBSCRIPTION RIGHTS CERTIFICATE Delivery other than in the manner or to the addresses listed below will not constitute valid delivery.

EX-4.3 3 ex4_3.htm FORM OF SUBSCRIPTION RIGHTS CERTIFICATE ex4_3.htm
Exhibit 4.3
 
 
 
 
 
 
 
DELIVERY OPTIONS FOR SUBSCRIPTION RIGHTS CERTIFICATE
 
Delivery other than in the manner or to the addresses listed below will not constitute valid delivery.
If delivering by hand:
American Stock Transfer & Trust Company
Attn: Reorganization Department
59 Maiden Lane
New York, New York 10038
If delivering by mail or overnight courier:
American Stock Transfer & Trust Company
Operations Center
Attn: Reorganization Department
6201 15th Avenue
Brooklyn, New York 11219
 
PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY.
 
FORM 1-EXERCISE OF SUBSCRIPTION RIGHTS   FORM 2-DELIVERY TO DIFFERENT ADDRESS
     
To subscribe for shares pursuant to your Basic Subscription Right, please complete lines (a) and (c) and sign under Form 4 below.  To subscribe for shares pursuant to your Over-Subscription Right, please also complete line (b) and sign under Form 4 below.  To the extent you subscribe for more Shares than you are entitled under either the Basic Subscription Right or the Over-Subscription Right, you will be deemed to have elected to purchase the maximum number of shares for which you are entitled to subscribe under the Basic Subscription Right or Over-Subscription Right, as applicable.   If you wish for the Common Stock underlying your subscription rights, a certificate representing unexercised subscription rights or the proceeds of any sale of subscription rights to be delivered to an address different from that shown on the face of this Subscription Rights Certificate, please enter the alternate address below, sign under Form 4 and have your signature guaranteed under Form 4.
     
(a) EXERCISE OF BASIC SUBSCRIPTION RIGHT:    
     
I apply for ______________ shares x $ _____=                   $_______________
                 (no. of new shares)               (subscription price)    (amount enclosed)
   FORM 3-SIGNATURE
     
 (b) EXERCISE OF OVER-SUBSCRIPTION RIGHT   TO SUBSCRIBE: I acknowledge that I have received the Prospectus for this Rights Offering and I hereby irrevocably subscribe for the number of shares indicated above on the terms and conditions specified in the Prospectus.
     
I apply for ______________ shares x $ ________=              $_______________
                  (no. of new shares)              (subscription price)(amount enclosed)
    Signature(s): ______________________________________________________
     
(c) Total Amount of Payment Enclosed   =   $__________________   IMPORTANT: The signature(s) must correspond with the name(s) as printed on the reverse of this Subscription Rights Certificate in every particular, without alteration or enlargement, or any other change whatsoever.
     
METHOD OF PAYMENT (CHECK ONE)   FORM 4-SIGNATURE GUARANTEE
     
 o
Certificate check draft drawn on a U.S. bank, or postal telegraphic or express payable to “American Stock Transfer & Trust Company, as Subscription Agent.”
   This form must be completed if you have completed Forms 2.
 o
Wire transfer of immediately available funds directly to the account maintained by American Stock Transfer & Trust Company, LLC, as Subscription Agent, for purposes of accepting subscriptions in this Rights Offering at JPMorgan Chase Bank, 55 Water Street, New York, New York 10005, ABA #021000021, Account #530-354616 American Stock Transfer FBO SAMPLE Corporation, with reference to the rights holder's name.
  
 Signature Guaranteed: _______________________________________________
                                                                 (Name of Bank or Firm)
 
By:_______________________________________________________________
                                                                  (Signature of Officer)
     
IMPORTANT: The signature(s) must correspond with the name(s) as printed on the reverse of this Subscription Rights Certificate in every particular, without alteration or enlargement, or any other change whatsoever.   IMPORTANT:  The signature(s) should be guaranteed by an eligible guarantor institution (bank, stock broker, savings & loan association or credit union) with membership in an approved signature guarantee medallion program pursuant to Securities and Exchange Commission Rule 17Ad-15.
 
FOR INSTRUCTIONS ON THE USE OF SAMPLE CORPORATION SUBSCRIPTION RIGHTS CERTIFICATES, CONSULT THE ALTMAN GROUP, INC> , THE INFORMATION AGENT, AT (###) ###-####.