Form of Nominee Holder Certification

EX-4.8 10 a2233979zex-4_8.htm EX-4.8

Exhibit 4.8

 

[FORM OF NOMINEE HOLDER CERTIFICATION]

 

THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANY’S PROSPECTUS DATED               , 2018 (THE “PROSPECTUS”) AND ARE INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM BROADRIDGE CORPORATE ISSUER SOLUTIONS, INC., THE SUBSCRIPTION AGENT, BY CALLING ###-###-####.

 

FAMOUS DAVE’S OF AMERICA, INC.

 

SHARES OF COMMON STOCK

ISSUABLE UPON EXERCISE OF SUBSCRIPTION RIGHTS

 

NOMINEE HOLDER CERTIFICATION

 

The undersigned, a bank, broker, trustee, depository or other nominee holder of subscription rights (the “Subscription Rights”) to purchase shares of common stock, par value $0.01 per share (“Common Stock”), of Famous Dave’s of America, Inc., a Minnesota corporation (the “Company”), pursuant to the rights offering described in the Company’s prospectus dated                   , 2018 (the “Prospectus”), hereby certifies to the Company and Broadridge Corporate Issuer Solutions, Inc., as subscription agent for the rights offering, that (1) the undersigned has exercised on behalf of the beneficial owners thereof (which may include the undersigned), the basic subscription privilege as to the number of shares of Common Stock specified below on behalf of beneficial owners of Subscription Rights, (2) the undersigned has exercised on behalf of the beneficial owners thereof (which may include the undersigned), the over-subscription privilege as to the number of shares of Common Stock specified below, applicable only to those beneficial owners who have fully exercised their basic subscription privilege, listing separately below for each beneficial owner the basic subscription privilege and any associated over-subscription privilege (without identifying any such beneficial owner) and (3) with respect to any exercise of the over-subscription privilege described in (2) above, each such beneficial owner’s basic subscription privilege has been exercised in full:

 

 

 

Number of Shares
Owned on Record Date

 

Number of Shares Subscribed For
Pursuant to Basic Subscription
Privilege

 

Number of Shares Subscribed For
Pursuant to Over-Subscription
Privilege

 

1.

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

Name of Bank, Broker, Trustee, Depository or Other Nominee

 

By:

 

 

 

Authorized Signature

 

 

 

 

Name:

 

 

 

(Please print or type)

 

 

 

 

Title:

 

 

 

(Please print or type)

 

 

Provide the following information if applicable:

 

 

 

Depository Trust Company (“DTC”) Participant Number

 

 


 

Participant:

 

 

 

 

 

By:

 

 

 

Authorized Signature

 

 

 

 

Name:

 

 

 

(Please print or type)

 

 

 

 

Title:

 

 

 

(Please print or type)

 

 

DTC Confirmation Number(s)