Exhibit 10.2

NEITHER THIS WARRANT NOR THE SECURITIES FOR WHICH THIS WARRANT IS EXERCISABLE
HAVE BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE
SECURITIES COMMISSION OF ANY STATE IN RELIANCE UPON AN EXEMPTION FROM
REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES
ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN
EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN
AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE
SECURITIES LAWS AS EVIDENCED BY A LEGAL OPINION OF COUNSEL TO THE TRANSFEROR TO
SUCH EFFECT, THE SUBSTANCE OF WHICH SHALL BE REASONABLY ACCEPTABLE TO THE
COMPANY.

GENERAL CANNABIS CORP

2020 A WARRANT

TO PURCHASE SHARES OF COMMON STOCK

No. GCCW-__

GENERAL CANNABIS CORP, a Colorado corporation (the “Company”), for value
received, hereby certifies that _________________, or registered assigns (the
“Holder”), is entitled to purchase from the Company, at the Purchase Price,
______________ (__) shares of the duly authorized, validly issued, fully paid
and nonassessable shares the Company’s common stock with a par value of $0.001
(“Common Stock”), at any time or from time to time prior to 5:00 P.M., New York
City time, on the Expiration Date, all subject to the terms, conditions and
adjustments set forth below.  

This is the Warrant (the “Warrant”, such term to include any such warrants
issued in substitution therefor) referred to in and issued pursuant to the terms
of that certain Securities Purchase Agreement between the Company and the Holder
(the “Agreement”).  This Warrant is entitled to the benefits of the Agreement
and is also subject to the obligations imposed by the Agreement, including as
relates to any restrictions on transfer of ownership of the Warrant.

Capitalized terms used herein and not otherwise defined herein shall have the
meanings assigned such terms in the Agreement.

1.

Definitions.  As used herein, unless the context otherwise requires, the
following terms shall have the meanings indicated:

“Acquisition” shall mean any sale or other disposition of all or substantially
all of the assets of the Company, or any reorganization, consolidation, or
merger of the Company where the holders of the Company’s securities before the
transaction beneficially own less than one-third of the outstanding voting
securities of the surviving entity after the transaction.

“Business Day” shall mean any day other than a Saturday or a Sunday or a day on
which commercial banking institutions in the City of New York are authorized by
law to be closed.  Any reference to “days” (unless Business Days are specified)
shall mean calendar days.  In any circumstance where a date of determination
under this Warrant falls on a date that is not a Business Day, it shall be
deemed to be the next Business Day.

“Common Stock” shall have the meaning assigned to it in the introduction to this
Warrant, such term to include any stock into which such Common Stock shall have
been changed or any stock resulting from any reclassification of such Common
Stock, and all other stock of any class or classes (however designated) of the
Company the holders of which have the right, without limitation as to amount,
either to all or to a share of the balance of current dividends and liquidating
dividends after the payment of dividends and distributions on any shares
entitled to preference.

“Company” shall have the meaning assigned to it in the introduction to this
Warrant, such term to include any corporation or other entity which shall
succeed to or assume the obligations of the Company hereunder in compliance with
Section 4.

--------------------------------------------------------------------------------

 

“Exchange Act” shall mean the Securities Exchange Act of 1934, as amended from
time to time, and the rules and regulations thereunder, or any successor
statute.

“Expiration Date” shall mean December 31, [2020] [2021] [2022].

“Person” shall mean any individual, firm, partnership, corporation, trust, joint
venture, association, joint stock company, limited liability company,
unincorporated organization or any other entity or organization, including a
government or agency or political subdivision thereof, and shall include any
successor (by merger or otherwise) of such entity.

“Purchase Price” shall mean $0.45 per Warrant Share, subject to adjustment and
readjustment from time to time as provided in Section 3, and, as so adjusted or
readjusted, shall remain in effect until a further adjustment or readjustment
thereof is required by Section 3.

“Securities Act” shall mean the Securities Act of 1933, as amended from time to
time, and the rules and regulations thereunder, or any successor statute.

“Warrant Shares” shall mean the number of shares of Common Stock that can be
purchased upon exercise of this Warrant.

2.

Exercise of Warrant.

2.1.

Manner of Exercise; Payment of the Purchase Price.

(a)

This Warrant may be exercised by the Holder hereof, in whole or in part, at any
time or from time to time prior to the Expiration Date, by surrendering to the
Company at its principal office this Warrant, with the form of Election to
Purchase Shares attached hereto as Exhibit ‘A’ (or a reasonable facsimile
thereof) duly executed by the Holder and accompanied by payment of the Purchase
Price for the number of shares of Common Stock specified in such form.

(b)

Payment of the Purchase Price shall be made in United States currency by cash or
delivery of a check payable to the order of the Company or by wire transfer to
the Company.

2.2.

When Exercise Effective.  Each exercise of this Warrant shall be deemed to have
been effected immediately prior to the close of business on the Business Day on
which this Warrant shall have been surrendered to, and the Purchase Price shall
have been received by, the Company and at such time the Person or Persons in
whose name or names any certificate or certificates for shares of Common Stock
shall be issuable upon such exercise shall be deemed to have become the holder
or holders of record thereof for all purposes.

2.3.

Delivery of Stock Certificates, Etc.; Charges, Taxes and Expenses.

(a)

As soon as practicable after each exercise of this Warrant, in whole or in part,
the Company shall cause to be issued in such denominations as may be requested
by the Holder in the Election to Purchase Shares, in the name of and delivered
to the Holder or, subject to applicable securities laws, as the Holder may
direct, the following:

(i)

a certificate or certificates for the number of Warrant Shares to which the
Holder shall be entitled upon such exercise plus, if applicable, in lieu of
issuance of any fractional share to which the Holder would otherwise be
entitled, a Company check pursuant to Section 8.4, and

(ii)

in case such exercise is for less than all of the Warrant Shares a new Warrant
or Warrants of like tenor, covering the balance of the Warrant Shares.

(b)

Issuance of Warrant Shares upon the exercise of this Warrant shall be made
without charge to the Holder hereof for any issue tax or other incidental
expense, in respect of the issuance of such certificates, all of which such
taxes and expenses shall be paid by the Company; provided, however, the Holder
shall pay any applicable transfer or similar tax resulting from the issuance of
Warrant Shares to any Person other than the Holder.

2.4.

Beneficial Ownership Limitation.  The Company shall not effect any exercise of
this Warrant, and a Holder shall not have the right to exercise any portion of
this Warrant, pursuant to Section 2 or otherwise, to the extent that after
giving effect to such issuance after exercise the Holder (together with the
Holder’s affiliates, and any other person or entity acting as a group together
with the Holder or any of the Holder’s affiliates),

2

--------------------------------------------------------------------------------

 

would beneficially own in excess of the Beneficial Ownership Limitation (as
defined below). For purposes of the foregoing sentence, the number of shares of
Common Stock beneficially owned by the Holder and its affiliates shall include
the number of shares of Common Stock issuable upon exercise of this Warrant with
respect to which such determination is being made, but shall exclude the number
of shares of Common Stock which would be issuable upon (A) exercise of the
remaining, nonexercised portion of this Warrant beneficially owned by the Holder
or any of its affiliates and (B) exercise or conversion of the unexercised or
nonconverted portion of any other securities of the Company (including, without
limitation, any other Common Stock equivalents), subject to a limitation on
conversion or exercise analogous to the limitation contained herein,
beneficially owned by the Holder or any of its affiliates. Except as set forth
in the preceding sentence, for purposes of this Section 2.4, beneficial
ownership shall be calculated in accordance with Section 13(d) of the Exchange
Act and the rules and regulations promulgated thereunder, it being acknowledged
by the Holder that the Company is not representing to the Holder that such
calculation is in compliance with Section 13(d) of the Exchange Act and the
Holder is solely responsible for any schedules required to be filed in
accordance therewith. To the extent that the limitation contained in this
Section 2.4 applies, the determination of whether this Warrant is exercisable
(in relation to other securities owned by the Holder together with any
affiliates) and of which portion of this Warrant is exercisable shall be in the
sole discretion of the Holder, and the submission of a an Election to Purchase
Shares (in the form attached hereto as Exhibit ‘A’) shall be deemed to be the
Holder’s determination of whether this Warrant is exercisable (in relation to
other securities owned by the Holder together with any affiliates) and of which
portion of this Warrant is exercisable, in each case subject to the Beneficial
Ownership Limitation, and the Company shall have no obligation to verify or
confirm the accuracy of such determination. In addition, a determination as to
any group status as contemplated above shall be determined in accordance with
Section 13(d) of the Exchange Act and the rules and regulations promulgated
thereunder. Upon the written or oral request of a Holder, the Company shall
within two trading days confirm orally and in writing to the Holder the number
of shares of Common Stock then outstanding. In any case, the number of
outstanding shares of Common Stock shall be determined after giving effect to
the conversion or exercise of securities of the Company, including this Warrant,
by the Holder or its affiliates since the date as of which such number of
outstanding shares of Common Stock was reported. The “Beneficial Ownership
Limitation” shall be 9.9% of the number of shares of the Common Stock
outstanding immediately after giving effect to the issuance of shares of Common
Stock issuable upon exercise of this Warrant. The Holder, upon not less than 61
days’ prior notice to the Company, may increase or decrease the Beneficial
Ownership Limitation provisions of this Section 2.4 by an amount determined by
the Holder in its sole discretion. Any such increase or decrease will not be
effective until the 61st day after such notice is delivered to the Company. The
provisions of this Section 2.4 shall be construed and implemented in a manner
otherwise than in strict conformity with the terms of this Section 2.4 as may be
necessary to correct any portion hereof which may be defective or inconsistent
with the intended Beneficial Ownership Limitation herein contained or to make
changes or supplements necessary or desirable to properly give effect to such
limitation. The limitations contained in this Section 2.4 shall apply to a
successor holder of this Warrant.

3.

Stock Dividends, Splits.  In the event that the Company shall (a) issue
additional shares of the Common Stock as a dividend or other distribution on the
outstanding Common Stock, (b) subdivide its outstanding shares of Common Stock,
or (c) combine its outstanding shares of Common Stock into a smaller number of
shares of Common Stock, then, in each such event, the Purchase Price shall,
simultaneously with the happening of such event, be adjusted by multiplying the
then Purchase Price by a fraction, the numerator of which shall be the number of
shares of Common Stock outstanding immediately prior to such event and the
denominator of which shall be the number of shares of Common Stock outstanding
immediately after such event, and the product so obtained shall thereafter be
the Purchase Price then in effect.  The Purchase Price, as so adjusted, shall be
readjusted in the same manner upon the happening of any successive event or
events described herein in this Section 3.  The number of Warrant Shares that
the Holder shall thereafter, be entitled to receive on the exercise hereof as
provided in Section 2, shall be adjusted to a number determined by multiplying
the number of Warrant Shares that would otherwise (but for the provisions of
this Section 3) be issuable on such exercise by a fraction of which the
numerator is the Purchase Price that would otherwise (but for the provisions of
this Section 3) be in effect, and the denominator is the Purchase Price in
effect on the date of such exercise.

4.

Warrants Callable by Company.  The Company shall have the right to redeem the
Warrants at any time if (i) the closing price of the Common Stock is above $5.00
per share (subject to adjustment and readjustment from time to time as provided
in Section 3) on ten (10) consecutive trading days following the Closing Date as
reported for the primary exchange or quotation system on which the Common Stock
is listed or quoted. If the Company has the right to call the Warrants and it
elects to do so, it will deliver written notice to the Holder that the Company
intends to redeem the Warrants at a price of $0.01 per Warrant (the “Call
Price”) on the thirtieth (30th) day following the date of that notice (or, if
that day is not a trading day for the Common Stock, then on the next following
day that is a trading day for the Common Stock (the “Call Date”), and the
Company shall then redeem all Warrants to the extent the Warrants have not been
exercised in accordance with Section 2 by the trading day preceding the Call
Date. The Company shall pay the redemption money to the Holders entitled to it
upon surrenders by them of their Warrants for redemption. The Company shall
cancel all Warrants surrendered for redemption.  All rights to exercise the
Warrants shall terminate as of the end of the trading day preceding the Call
Date.

3

--------------------------------------------------------------------------------

 

5.

Acquisition of Company.  In the event of a proposed Acquisition of the Company,
the Company shall provide the Holder with all information with respect to the
Acquisition that is otherwise provided to shareholders of the Company at such
time and from time to time during the pendency of the Acquisition, including
(but not limited to) the proposed price to be paid in the proposed Acquisition.
 The Holder shall have the right to exercise this Warrant on or prior to the
closing date with respect to the proposed Acquisition; if the Warrant is not
exercised on or prior to such closing date, the Warrant shall expire upon the
occurrence of the closing of the Acquisition.

6.

Certificate as to Adjustments.  In each case of any adjustment or readjustment
pursuant to Section 3, the Company at its expense shall promptly compute such
adjustment or readjustment in accordance with the terms of this Warrant and
prepare a certificate, signed by the Chief Financial Officer, or Corporate
Secretary of the Company, setting forth such adjustment or readjustment
(including but not limited to the Purchase Price and number of Warrant Shares
purchasable hereunder after giving effect to such adjustment or readjustment)
and showing in reasonable detail the method of calculation thereof.  Such
certificate shall constitute an amendment to this Warrant and shall be delivered
to the Holder in the manner provided in Section 9.  Upon request of the Holder,
the Company shall issue a new Warrant that reflects the terms of any such
adjustment or readjustment reflected in any such certificate issued hereunder.

Regardless of any adjustment or readjustment in the Purchase Price or the number
of Warrant Shares or other securities actually purchasable under the Warrant (or
the issuance of any certificate with respect thereto pursuant to this Section
6), any Warrant may continue to express the Purchase Price and the number of
Warrant Shares purchasable under the Warrant as the price and number of shares
were expressed on the Warrant when initially issued, subject to the Holder’s
rights hereunder to exchange the Warrant for a new Warrant that reflects the
terms of any such adjustment or readjustment.

7.

Reservation of Stock, Etc.  The Company shall at all times reserve and keep
available, solely for issuance and delivery upon exercise of the Warrants, 100%
of the number of Warrant Shares from time to time issuable upon exercise of all
Warrants at the time outstanding.  All Warrant Shares issuable upon exercise of
any Warrants shall be duly authorized and, when issued upon such exercise, shall
be validly issued and, in the case of shares, fully paid and nonassessable with
no liability on the part of the holders thereof, and, in the case of all
securities, shall be free from all taxes, liens, security interests,
encumbrances, preemptive rights and charges, except for the payment of
applicable transfer or similar taxes by the Holder upon issuance to a Person
other than the Holder.  Subsequent to the Expiration Date, no shares of stock
need be reserved in respect of any unexercised portion of this Warrant.

8.

Registration and Transfer of Warrants, Etc.

8.1.

Warrant Register; Ownership of Warrants.  Each Warrant issued by the Company
shall be numbered and shall be registered in a warrant register (the “Warrant
Register”) as it is issued and transferred, which Warrant Register shall be
maintained by the Company at its principal office or, at the Company’s election
and expense, by a warrant agent or the Company’s Transfer Agent.  The Company
shall be entitled to treat the registered Holder of any Warrant on the Warrant
Register as the owner in fact thereof for all purposes and shall not be bound to
recognize any equitable or other claim to or interest in such Warrant on the
part of any other Person, and shall not be affected by any notice to the
contrary, except that, if and when any Warrant is properly assigned in blank,
the Company may (but shall not be obligated to) treat the bearer thereof as the
owner of such Warrant for all purposes.  A Warrant, if properly assigned, may be
exercised by a new holder without a new Warrant first having been issued.

8.2.

Transfer of Warrants and Compliance with Securities Laws.

(a)

Neither this Warrant nor any interest therein may be transferred or assigned in
whole or in part without compliance with all applicable federal and state
securities laws by the Holder and the transferee or assignee thereof.  Subject
to such compliance, this Warrant and all rights hereunder are transferable in
whole or in part, without charge to the Holder hereof, upon surrender of this
Warrant with a properly executed Form of Assignment, attached hereto as Exhibit
B, at the principal office of the Company.  Upon any partial transfer, the
Company shall at its expense issue and deliver to the Holder a new Warrant of
like tenor, in the name of the Holder, which shall be exercisable for such
number of shares of Common Stock with respect to which rights under this Warrant
were not so transferred and to the transferee a new Warrant of like tenor, in
the name of the transferee, which shall be exercisable for such number of shares
of Common Stock with respect to which rights under this Warrant were so
transferred.

4

--------------------------------------------------------------------------------

 

(b)

The Holder, by acceptance of this Warrant, acknowledges that neither this
Warrant nor the Warrant Shares have been registered under the Securities Act and
represents and warrants to the Company that this Warrant is being acquired for
investment and not for distribution or resale, solely for Holder’s own account
and not as a nominee for any other person, and that Holder will not offer, sell,
pledge or otherwise transfer this Warrant or any Warrant Shares except (i) in
compliance with the requirements for an available exemption from the Securities
Act and any applicable state securities laws, or (ii) pursuant to an effective
registration statement or qualification under the Securities Act and any
applicable state securities laws.

8.3.

Replacement of Warrants.  On receipt by the Company of evidence reasonably
satisfactory to the Company of the loss, theft, destruction or mutilation of
this Warrant and, in the case of any such loss, theft or destruction of this
Warrant, on delivery of an indemnity agreement reasonably satisfactory in form
and amount to the Company or, in the case of any such mutilation, on surrender
of such Warrant to the Company at its principal office and cancellation thereof,
the Company at its expense shall execute and deliver, in lieu thereof, a new
Warrant of like tenor.

8.4.

Fractional Shares.  Notwithstanding any adjustment pursuant to Section 3, if the
Common Stock shall be listed on a national securities exchange, the Company then
shall not be required to issue fractions of shares upon exercise of this Warrant
or to distribute certificates which evidence fractional shares.  In lieu of
fractional shares, the Company then shall make payment to the Holder of an
amount in cash equal to such fraction multiplied by the closing bid price on the
principal trading market of a share of Common Stock on the date of exercise of
this Warrant.

7.5

No  Impairment.  The Company will not, by any voluntary action, avoid or seek to
avoid the observance or performance of any of the terms to be observed or
performed hereunder by the Company, but will at all times in good faith assist
in the carrying out of all the provisions of this Warrant and in the taking of
all such action as may be necessary or appropriate in order to protect the
rights of the holders of this Warrant against impairment.

9.

Notices.  Any notices, consents, waivers or other communications required or
permitted to be given hereunder must be in writing and will be deemed to have
been given (i) upon receipt, when delivered personally; (ii) three days after
being sent by U.S. certified mail, return receipt requested; or (iii) one day
after deposit with a nationally recognized overnight delivery service, in each
case properly addressed to the party to receive the same.  The addresses for
such communications shall be:

If to the Company:

General Cannabis Corp
6565 E. Evans Avenue
Denver, CO 80224
Attn:  Steve Gutterman

If to the Holder:

_____________
_____________
_____________
Attention:  _____________

Each party shall provide five days’ prior written notice to the other party of
any change in address.  Notwithstanding the foregoing, the exercise of this
Warrant shall be effective in the manner provided in Section 2.

10.

Amendments.  This Warrant and any term hereof may not be amended, modified,
supplemented or terminated, and waivers or consents to departures from the
provisions hereof may not be given, except by written instrument duly executed
by the party against which enforcement of such amendment, modification,
supplement, termination or consent to departure is sought.  

5

--------------------------------------------------------------------------------

11.

Descriptive Headings, Etc. The headings in this Warrant are for convenience of
reference only and shall not limit or otherwise affect the meaning of terms
contained herein.  Unless the context of this Warrant otherwise requires:
 (a) words of any gender shall be deemed to include each other gender; (b) words
using the singular or plural number shall also include the plural or singular
number, respectively; (c) the words “hereof”, “herein” and “hereunder” and words
of similar import when used in this Warrant shall refer to this Warrant as a
whole and not to any particular provision of this Warrant, and Section and
paragraph references are to the Sections and paragraphs of this Warrant unless
otherwise specified; (d) the word “including” and words of similar import when
used in this Warrant shall mean “including, without limitation,” unless
otherwise specified; (e) ”or” is not exclusive; and (f) provisions apply to
successive events and transactions.

12.

Governing Law.  This Warrant shall be governed by, and construed in accordance
with, the laws of the State of New York (without giving effect to the conflict
of laws principles thereof).

13.

Judicial Proceedings.  Any legal action, suit or proceeding brought against the
Company with respect to this Warrant may be brought in any court located in
Denver County, State of Colorado, and by execution and delivery of this Warrant,
the Company hereby irrevocably and unconditionally waives any claim (by way of
motion, as a defense or otherwise) of improper venue, that it is not subject
personally to the jurisdiction of such court, that such courts are an
inconvenient forum or that this Warrant or its subject matter may not be
enforced in or by such court.

[Signature Page Follows]

6

--------------------------------------------------------------------------------

IN WITNESS WHEREOF, the Company has caused this Warrant to be issued as of the
___ day of_______, 2020.

 

GENERAL CANNABIS CORP

 

 

 

 

 

 

 

By:

 

 

Name:

Steve Gutterman

 

Title:

Chief Executive Officer

7

--------------------------------------------------------------------------------

EXHIBIT A to
2020 A Warrant

GENERAL CANNABIS CORP

ELECTION TO PURCHASE SHARES

The undersigned hereby irrevocably elects to purchase __ shares of no par value
Common Stock (“Common Stock”), of GENERAL CANNABIS CORP (the “Company”) by
exercising the warrant (the “Warrant”) dated _______ __, 20__ and issued to the
undersigned, and hereby makes payment of $___________ therefor.  The undersigned
hereby requests that the certificate(s) for such shares and payment for
fractional shares be issued and made as follows:

ISSUE/PAY TO*: _____________________________________________________________

(NAME)

____________________________________________________________________________

(ADDRESS, INCLUDING ZIP CODE)

____________________________________________________________________________

(SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER)

DELIVER TO: ________________________________________________________________

(NAME)

____________________________________________________________________________

(ADDRESS, INCLUDING ZIP CODE)

If the number of shares of Common Stock purchased hereby is less than the number
of shares of Common Stock covered by the Warrant, the undersigned requests that
a new Warrant representing the number of shares of Common Stock not so purchased
be issued and delivered as follows:

ISSUE TO*: __________________________________________________________________

(NAME OF HOLDER)

____________________________________________________________________________

(ADDRESS, INCLUDING ZIP CODE)

DELIVER TO: ________________________________________________________________

(NAME)

____________________________________________________________________________

(ADDRESS, INCLUDING ZIP CODE)

In order to induce the Company to give instructions to its transfer agent to
issue the shares of Common Stock being purchased upon exercise of the Warrant,
the undersigned hereby represents and warrants that the undersigned is an
“accredited investor” as that term is defined in Regulation D under the
Securities Act of 1933, as amended.

[Signature page follows]

                                         

 

*   If other than the Holder specified on the Warrant delivered with this
Election to Purchase Shares, the transfer is subject to compliance with
applicable securities laws and the payment by the Holder of any applicable
transfer or similar taxes.

A-1

--------------------------------------------------------------------------------

[Signature Page to Election to Purchase Shares]

Individual(s):

 

 

 

 

 

 

 

 

 

 

 

Signature (exactly as name appears on stock certificate(s) tendered)

 

Signature of spouse, joint tenant, tenant in common, or other required signature

 

 

 

 

 

 

Print or type name

 

Print or type name

 

 

 

 

 

 

Entity:

 

 

 

 

 

 

 

 

 

 

 

Print or type name of entity (exactly as name appears on stock certificate(s)
tendered)

 

 

 

 

 

 

 

 

By:

 

 

 

Name:

Title:

 

 

(Unless waived by the Company, all signatures must be guaranteed by an eligible
guarantor institution that is a member of a recognized medallion signature
guarantee program.)

A-2

--------------------------------------------------------------------------------

EXHIBIT B to
2020 A Warrant

ASSIGNMENT

FOR VALUE RECEIVED, and subject to compliance with applicable securities laws
and payment of any applicable transfer taxes, the undersigned hereby sells,
assigns, and transfers unto the Assignee named below all of the rights of the
undersigned to purchase no par value Common Stock of GENERAL CANNABIS CORP (the
“Company”) represented by the Warrant dated ______________, with respect to the
number of shares of Common Stock set forth below:

Name of Assignee

 

Address

 

No. of
Warrant Shares

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and does hereby irrevocably constitute and appoint any officer of the Company to
make such transfer on the books of the Company maintained for that purpose, with
full power of substitution in the premises.

Date: ____________________

(Unless waived by the Company, all signatures must be guaranteed by an eligible
guarantor institution that is a member of a recognized medallion signature
guaranty program.)

B-1