Additional abbreviations may also be used though not in the above list.

EX-4.1 5 d773198dex41.htm EX-4.1 EX-4.1

Exhibit 4.1

 

NS NeuroSigma ® NeuroSigma, Inc. INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE SEE REVERSE FOR CERTAIN DEFINITIONS CUSIP 64129W 10 1 THIS CERTIFIES THAT SPECIMEN IS THE RECORD HOLDER OF FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK, $0.0001 PAR VALUE, PER SHARE, OF NeuroSigma, Inc. transferable on the books of the Corporation in person or by duly authorized attorney upon surrender of this Certificate properly endorsed. This Certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar. Witness the facsimile signatures of the Corporation’s duly authorized officers. Dated: SENIOR VICE PRESIDENT, CHIEF ADMINISTRATIVE OFFICER, GENERAL COUNSEL AND CORPORATE SECRETARY PRESIDENT AND CHIEF EXECUTIVE OFFICER COUNTERSIGNED AND REGISTERED: AMERICAN STOCK TRANSFER & TRUST COMPANY, LLC (Brooklyn, NY) TRANSFER AGENT AND REGISTRAR By: AUTHORIZED SIGNATURE

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, assign and transfer unto

 

PLEASE INSERT SOCIAL SECURITY OR OTHER

IDENTIFYING NUMBER OF ASSIGNEE

  

    

 

  

 

                                                                                                                                                                                                                             

PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING POSTAL ZIP CODE, OF ASSIGNEE

 

                                                                                                                                                                                                                             

 

                                                                                                                                                                                                                             

                                                                                                                                                                                                            Shares

of the Common Stock represented by this Certificate, and do(es) hereby irrevocably constitute and appoint

                                                                                                                                                                                                            Attorney to transfer the said Shares on the books of the within-named Corporation with full power of substitution.

 

Dated

  

 

   

 

  X  

 

  X  

 

  NOTICE:   THE SIGNATURE(S) TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) OF THE STOCKHOLDER(S) AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER.

Signature(s) Guaranteed

 

 

   
THE SIGNATURE(S) MUST 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 S.E.C. RULE 17Ad-15. GUARANTEES BY A NOTARY PUBLIC ARE NOT ACCEPTABLE. SIGNATURE GUARANTEES MUST NOT BE DATED.