MISSION COMMUNITY BANCORP Incorporated under the laws of the State ofCalifornia SUBSCRIPTION RIGHTS CERTIFICATE Evidencing Subscription Rights to PurchaseShares of Common Stock of Mission Community Bancorp and Related Warrants to Purchase Shares of Common Stockof Mission Community Bancorp Subscription Price: $5.00 per Share and Related Warrant THE SUBSCRIPTION RIGHTS WILLEXPIRE IF NOT EXERCISED ON OR BEFORE 5:00 PM., PACIFICTIME, ON ,2010, UNLESS EXTENDED BY THE COMPANY
Exhibit 4.12
RIGHTS CERTIFICATE #: |
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THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANYS PROSPECTUS DATED , 2010 (THE PROSPECTUS) AND ARE INCORPORATED HEREIN BY REFERENCE, COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM MISSION COMMUNITY BANCORP, 3380 SOUTH HIGUEROA, SAN LUIS OBISPO, CA 93401, (805) 782-5000.
MISSION COMMUNITY BANCORP
Incorporated under the laws of the State of California
SUBSCRIPTION RIGHTS CERTIFICATE
Evidencing Subscription Rights to Purchase Shares of
Common Stock of Mission Community Bancorp and
Related
Warrants to Purchase Shares of Common Stock of Mission Community Bancorp
Subscription Price: $5.00 per Share and Related Warrant
THE SUBSCRIPTION RIGHTS WILL EXPIRE IF NOT EXERCISED ON
OR BEFORE 5:00 PM., PACIFIC TIME, ON , 2010,
UNLESS EXTENDED BY THE COMPANY
REGISTERED
OWNER:
THIS CERTIFIES THAT the registered owner whose name is inscribed hereon is the owner of the number of non-transferable subscription rights (Subscription Rights) set forth above. Each whole Right entitles the holder thereof to subscribe for and purchase one share of Common Stock, without par value, of Mission Community Bancorp (Share), and one related warrant to purchase one Share (Warrant) at a subscription price of $5.00, pursuant to a Subscription Rights Offering (the Subscription Rights Offering), on the terms and subject to the conditions set forth in the Prospectus and the Instructions as to Use of Subscription Rights Certificate accompanying this Subscription Rights Certificate. The Subscription Rights represented by this Subscription Rights Certificate may be exercised by completing Form 1 and any other appropriate forms on the reverse side hereof and by returning the full payment of the subscription price for each Share and related Warrant in accordance with the Instructions as to Use of Subscription Rights Certificate that accompany this Subscription Rights Certificate.
Witness the seal of Mission Community Bancorp and the signatures of its duly authorized officers.
Dated: , 2010
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Secretary |
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DELIVERY OF SUBSCRIPTION RIGHTS CERTIFICATE
If delivering by Hand/Mail/Overnight Courier
Mission Community Bancorp
3380 South Higuera Street
San Luis Obispo, California 93401
Attn: Cindy Harrison
FORM 1EXERCISE OF SUBSCRIPTION RIGHTS
To subscribe for shares and warrants pursuant to your Subscription Rights, please complete lines (a) and (b) and sign under Form 3 below.
(a) EXERCISE OF SUBSCRIPTION RIGHTS:
I apply for shares x $5.00=$ (no. of new shares) (subscription price) (amount enclosed)
(b) METHOD OF PAYMENT (CHECK ONE)
o Check or bank draft drawn on a U.S. bank payable to Mission Community Bancorp.
Funds paid by uncertified check may take at least five business days to clear.
o Wire transfer of immediately available funds directly to the account maintained by Mission Community Bancorp for purposes of accepting subscriptions in this Rights Offering at Mission Community Bank, 3380 South Higuera Street, San Luis Obispo, California 93401, ABA # 122242649, Account # , with reference to the rights holders name.
(c) ASSIGNMENT
If you are an assignee of this Subscription Rights Certificate you must submit the originally executed assignment form, obtained from Mission Community Bancorp, signed by the original Subscription Rights Certificate holder, as well as this completed subscription rights certificate.
o Check here if you are an Assignee of this Subscription Rights Certificate.
FORM 2DELIVERY TO DIFFERENT ADDRESS
If you wish for the Shares and Warrants underlying your 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 3 and have your signature guaranteed under Form 4.
FORM 3SIGNATURE
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.
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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 any change whatsoever.
FORM 4SIGNATURE GUARANTEE
This form must be completed if you have completed Form 2.
Signature Guaranteed: |
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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.
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