Exhibit 10.3 [f8k_naturewell.htm]

 

WARRANT AGREEMENT

 

THESE SECURITIES AND THE SECURITIES ISSUABLE UPON THEIR EXERCISE HAVE NOT BEEN
REGISTERED UNDER THE SECURITIES ACT OF 1933 AND MAY NOT BE TRANSFERRED UNLESS
COVERED BY AN EFFECTIVE REGISTRATION STATEMENT UNDER SAID ACT, A "NO ACTION"
LETTER FROM THE SECURITIES AND EXCHANGE COMMISSION WITH RESPECT TO SUCH
TRANSFER, A TRANSFER MEETING THE REQUIREMENTS OF RULE 144 OF THE SECURITIES AND
EXCHANGE COMMISSION, OR AN OPINION OF COUNSEL SATISFACTORY TO THE ISSUER TO THE
EFFECT THAT ANY SUCH TRANSFER IS EXEMPT FROM SUCH REGISTRATION.

 

NATUREWELL, INCORPORATED

 

WARRANT NO.

 

Dated:

 

NatureWell, Incorporated, a corporation organized under the laws of the State of
Delaware (the "Company"), hereby certifies that, for value received from
________________ (the "Holder"), is entitled, subject to the terms set forth
below, to purchase from the Company up to a total of _______________ (________)
shares of the Common Stock, $0.0001 par value per share (the "Common Stock"), of
the Company (each such share, a "Warrant Share" and all such shares, the
"Warrant Shares") at an exercise price equal to $0.60 per share. The Warrant may
be exercised any time after issuance through and including the fifth (5th)
anniversary of its original issuance (the "Expiration Date"), subject to the
terms and conditions set out below. The Holder acknowledges that on March 13,
2013, the Company entered into an Agreement and Plan of Merger (the “Merger”)
with Brazil Interactive Media, Inc. (“BIMI”) whereby the Company acquired all of
the issued and outstanding shares of Common Stock of BIMI, pursuant to the terms
and conditions of that agreement. As a result of the Merger, the Company is, as
of the date of this Agreement, taking steps to change its name to “Brazil
Interactive Media, Inc.”.

 

1. Registration of Warrant. The Company shall register this Warrant, upon
records to be maintained by the Company for that purpose (the "Warrant
Register"), in the name of the record Holder hereof from time to time. The
Company may deem and treat the registered Holder of this Warrant as the absolute
owner hereof for the purpose of any exercise hereof or any distribution to the
Holder, and for all other purposes, and the Company shall not be affected by
notice to the contrary.

 

2. Registration of Transfers and Exchanges.

 

 

 

(a) The Company or the transfer agent shall enter or record the transfer of any
portion of this Warrant in the Warrant Register, upon surrender of this Warrant
to the Company at the office specified herein or pursuant to Section 11. Upon
any such registration or transfer, a new warrant to purchase Common Stock, in
substantially the form of this Warrant (any such new warrant, a "New Warrant"),
evidencing the portion of this Warrant so transferred shall be issued to the
transferee and a New Warrant evidencing the remaining portion of this Warrant
not so transferred, if any, shall be issued to the Holder. The acceptance of the
New Warrant by the transferee thereof shall be deemed the acceptance of such
transferee of all of the rights and obligations of a holder of a Warrant.

 

(b) This Warrant is exchangeable, upon the surrender hereof by the Holder to the
office of the Company specified herein or pursuant to Section 3(b) for one or
more New Warrants, evidencing in the aggregate the right to purchase the number
of Warrant Shares which may then be purchased hereunder. Any such New Warrant
will be dated the date of such exchange.

 

3. Duration and Exercise of Warrants.

 

(a) This Warrant shall be exercisable by the registered Holder on any business
day before 5:00 P.M., Boston time, at any time and from time to time on or after
the date hereof to and including the Expiration Date. At 5:00 P.M., Boston time
on the Expiration Date, the portion of this Warrant not exercised prior thereto
shall be and become void and of no value. Prior to the Expiration Date, the
Company may not call or otherwise redeem this Warrant without the prior written
consent of the Holder.

 

(b) Subject to Sections 2(b), 6 and 10, upon surrender of this Warrant, with the
Form of Election to Purchase attached hereto duly completed and signed, to the
Company at its address for notice set forth in Section 11 and upon payment of
the Exercise Price multiplied by the number of Warrant Shares that the Holder
intends to purchase hereunder, in the manner provided hereunder, all as
specified by the Holder in the Form of Election to Purchase, the Company shall
promptly (but in no event later than 5 business days after the Date of Exercise
(as defined herein)) issue or cause to be issued and cause to be delivered to or
upon the written order of the Holder and in such name or names as the Holder may
designate, a certificate for the Warrant Shares issuable upon such exercise,
free of restrictive legends except either (i) in the event that a registration
statement covering the resale of the Warrant Shares and naming the Holder as a
selling stockholder thereunder is not then effective or the Warrant Shares are
not freely transferable without volume restrictions pursuant to Rule 144(k)
promulgated under the Securities Act of 1933, as amended (the "Securities Act"),
or (ii) if this Warrant shall have been issued pursuant to a written agreement
between the original Holder and the Company, as required by such agreement. In
the case of (i) above, the Warrant Shares will bear a Securities Act restrictive
legend. Any person so designated by the Holder to receive Warrant Shares shall
be deemed to have become holder of record of such Warrant Shares as of the Date
of Exercise (as defined in this subsection) of this Warrant. A "Date

 

 

of Exercise" means the date on which the Company shall have received (i) this
Warrant (or any New Warrant, as applicable), with the Form of Election to
Purchase attached hereto (or attached to such New Warrant) appropriately
completed and duly signed, and (ii) payment of the Exercise Price for the number
of Warrant Shares so indicated by the holder hereof to be purchased.

 

(c) This Warrant shall be exercisable, either in its entirety or, from time to
time, for a portion of the number of Warrant Shares. If less than all of the
Warrant Shares which may be purchased under this Warrant are exercised at any
time, the Company shall issue or cause to be issued, at its expense, a New
Warrant evidencing the right to purchase the remaining number of Warrant Shares
for which no exercise has been evidenced by this Warrant. In the event the
Common Stock representing the Warrant Shares is not delivered per the written
instructions of the Holder, within five (5) business days after the Notice of
Election and Warrant is received by the Company (the “Delivery Date”), then in
such event the Company shall pay to Holder two percent (2.0%) in cash, of the
dollar value of the Warrant Shares to be issued per each day after the Delivery
Date that the Warrant Shares are not delivered. The Company acknowledges that
its failure to deliver the Warrant Shares by the Delivery Date will cause the
Holder to suffer damages in an amount that will be difficult to ascertain.
Accordingly, the parties agree that it is appropriate to include in this Warrant
a provision for liquidated damages. The parties acknowledge and agree that the
liquidated damages provision set forth in this section represents the parties’
good faith effort to quantify such damages and, as such, agree that the form and
amount of such liquidated damages are reasonable and will not constitute a
penalty. The payment of liquidated damages shall not relieve the Company from
its obligations to deliver the Common Stock pursuant to the terms of this
Warrant. The Company shall make any payments incurred under this Section 3 in
immediately available funds within five (5) business days from the date of
issuance of the applicable Warrant Shares. Nothing herein shall limit Holder’s
right to pursue actual damages or cancel the Notice of Election for the
Company’s failure to issue and deliver Common Stock to the Holder within seven
(7) business days following the Delivery Date.

 

4. Registration Rights. As more fully described in that Preferred Stock
Registration Rights Agreement between the Company and the Investors, the Company
shall file a registration statement with the Commission within forty-five (45)
days following Closing Date (the “Filing Date”) covering the shares of Common
Stock underlying the Series H Stock. The Company agrees not to include any other
shares for registration in said registration statement without the Investors’
written consent. Subject to the terms of this Agreement, the Company shall use
its best efforts to cause the Registration Statement to be declared effective
under the Securities Act as promptly as possible after the filing thereof, but
in any event prior to the applicable Effectiveness Date, and shall use its best
efforts to keep such Registration Statement continuously effective under the
Securities Act until all Registrable Securities covered by such Registration
Statement have been sold or may be sold without volume restrictions pursuant to
Rule 144(k) as determined by the counsel to the Company pursuant to a written
opinion letter to such effect, addressed and acceptable to the Company’s
transfer agent and the affected Holders (the “Effectiveness Period”). The
Company shall notify

 

 

the Investors via facsimile of the effectiveness of the Registration Statement
within one (1) Trading Day of the day that the Company receives notification of
the effectiveness from the Commission.

 

5. Payment of Taxes. The Company will pay all documentary stamp taxes
attributable to the issuance of Warrant Shares upon the exercise of this
Warrant; provided, however, that the Company shall not be required to pay any
tax that may be payable in respect of any transfer involved in the registration
of any certificates for Warrant Shares or Warrants in a name other than that of
the Holder. The Holder shall be responsible for all other tax liability that may
arise as a result of holding or transferring this Warrant or receiving Warrant
Shares upon exercise hereof.

 

6. Replacement of Warrant. If this Warrant is mutilated, lost, stolen or
destroyed, the Company shall issue or cause to be issued in exchange and
substitution for and upon cancellation hereof, or in lieu of and substitution
for this Warrant, a New Warrant, but only upon receipt of evidence reasonably
satisfactory to the Company of such loss, theft or destruction and indemnity, if
requested, satisfactory to it. Applicants for a New Warrant under such
circumstances shall also comply with such other reasonable regulations and
procedures and pay such other reasonable charges as the Company may prescribe.

 

7. Reservation of Warrant Shares. The Company covenants that it will at all
times reserve and keep available out of the aggregate of its authorized but
unissued Common Stock, solely for the purpose of enabling it to issue Warrant
Shares upon exercise of this Warrant as herein provided, the number of Warrant
Shares which are then issuable and deliverable upon the exercise of this entire
Warrant, free from preemptive rights or any other actual contingent purchase
rights of persons other than the Holder (taking into account the adjustments and
restrictions of Section 8. The Company covenants that all Warrant Shares that
shall be so issuable and deliverable shall, upon issuance and the payment of the
applicable Exercise Price in accordance with the terms hereof, be duly and
validly authorized, issued and fully paid and nonassessable. If the Company does
not have a sufficient amount of Common Stock authorized to reserve for the
Warrant Shares, it shall use its best efforts to place before shareholder vote a
proposal to increase the number of its authorized shares as soon as reasonably
practicable.

 

8. Certain Adjustments After January 1, 2014. The Exercise Price and number of
Warrant Shares issuable upon exercise of this Warrant are subject to adjustment
from time to time as set forth in this Section 8; provided, however, that
notwithstanding this Section 8, there shall be no adjustment to the Exercise
Price and number of Warrant Shares issuable upon exercise of this Warrant prior
to January 1, 2014. Upon each such adjustment of the Exercise Price pursuant to
this Section 8, the Holder shall thereafter prior to the Expiration Date be
entitled to purchase, at the Exercise Price resulting from such adjustment, the
number of Warrant Shares obtained by multiplying the Exercise Price in effect
immediately prior to such adjustment by the number of Warrant Shares issuable
upon exercise of this Warrant immediately prior to

 

 

such adjustment and dividing the product thereof by the Exercise Price resulting
from such adjustment.

 

(a) An adjustment shall be made, if the Company, at any time while this Warrant
is outstanding (i) pays a stock dividend (except scheduled dividends paid on
outstanding preferred stock as of the date hereof which contain a stated
dividend rate) or otherwise make a distribution or distributions on shares of
its Common Stock or on any other class of capital stock and not the Common Stock
payable in shares of Common Stock, (ii) subdivides outstanding shares of Common
Stock into a larger number of shares, or (iii) combines outstanding shares of
Common Stock into a smaller number of shares. If either (i), (ii) or (iii),
above occurs, the Exercise Price shall be multiplied by a fraction of which the
numerator shall be the number of shares of Common Stock (excluding treasury
shares, if any) outstanding before such event and of which the denominator shall
be the number of shares of Common Stock (excluding treasury shares, if any)
outstanding after such event. Any adjustment made pursuant to this Section shall
become effective immediately after the record date for the determination of
stockholders entitled to receive such dividend or distribution and shall become
effective immediately after the effective date in the case of a subdivision or
combination, and shall apply to successive subdivisions and combinations.

 

(b) In case of any reclassification of the Common Stock, any consolidation or
merger of the Company with or into another person, the sale or transfer of all
or substantially all of the assets of the Company or any compulsory share
exchange pursuant to which the Common Stock is converted into other securities,
cash or property, then the Holder shall have the right thereafter to exercise
this Warrant only into the shares of stock and other securities and property
receivable upon or deemed to be held by holders of Common Stock following such
reclassification, consolidation, merger, sale, transfer or share exchange, and
the Holder shall be entitled upon such event to receive such amount of
securities or property equal to the amount of Warrant Shares such Holder would
have been entitled to had such Holder exercised this Warrant immediately prior
to such reclassification, consolidation, merger, sale, transfer or share
exchange. The terms of any such consolidation, merger, sale, transfer or share
exchange shall include such terms so as to continue to give to the Holder the
right to receive the securities or property set forth in this Section 8(b) upon
any exercise following any such reclassification, consolidation, merger, sale,
transfer or share exchange.

 

(c) If the Company, at any time while this Warrant is outstanding, shall
distribute to all holders of Common Stock (and not to holders of this Warrant)
evidence of its indebtedness or assets or rights or warrants to subscribe for or
purchase any security (excluding those referred to in Sections 8(a), (b) and
(d)), then in each such case the Exercise Price shall be determined by
multiplying the Exercise Price in effect immediately prior to the record date
fixed for determination of stockholders entitled to receive such distribution by
a fraction of which the denominator shall be the Exercise Price determined as of
the record date mentioned above, and of which the numerator shall be such
Exercise Price on such record date less the then fair market value at such
record date of the portion of such assets or evidence of indebtedness so

 

 

distributed applicable to one outstanding share of Common Stock as determined by
the Company's independent certified public accountants that regularly examines
the financial statements of the Company (the "Appraiser").

 

(d) If, at any time while this Warrant is outstanding, the Company shall issue
or cause to be issued rights or warrants to acquire or otherwise sell or
distribute shares of Common Stock for a consideration per share less than the
lower of the Exercise Price then in effect and the then fair market value of the
Common Stock, then, forthwith upon such issue or sale, the Exercise Price shall
be reduced to the price (calculated to the nearest one hundredth of a cent)
determined by multiplying the Exercise Price in effect immediately prior thereto
by a fraction, the numerator of which shall be the sum of (i) the number of
shares of Common Stock outstanding immediately prior to such issuance, and (ii)
the number of shares of Common Stock which the aggregate consideration received
(or to be received, assuming exercise or conversion in full of such rights,
warrants and convertible securities) for the issuance of such additional shares
of Common Stock would purchase at the Exercise Price, and the denominator of
which shall be the sum of the number of shares of Common Stock outstanding
immediately after the issuance of such additional shares. Such adjustment shall
be made successively whenever such an issuance is made.

 

(e) For the purposes of this Section 8, the following clauses shall also be
applicable:

 

(i) Record Date. In case the Company shall take a record of the holders of its
Common Stock for the purpose of entitling them (A) to receive a dividend or
other distribution payable in Common Stock or in securities convertible or
exchangeable into shares of Common Stock, or (B) to subscribe for or purchase
Common Stock or securities convertible or exchangeable into shares of Common
Stock, then such record date shall be deemed to be the date of the issue or sale
of the shares of Common Stock deemed to have been issued or sold upon the
declaration of such dividend or the making of such other distribution or the
date of the granting of such right of subscription or purchase, as the case may
be.

 

(ii) Treasury Shares. The number of shares of Common Stock outstanding at any
given time shall not include shares owned or held by or for the account of the
Company, and the disposition of any such shares shall be considered an issue or
sale of Common Stock.

 

(f) All calculations under this Section 8 shall be made to the nearest cent or
the nearest 1/100th of a share, as the case may be.

 

(g) Whenever the Exercise Price is adjusted pursuant to Section 8(c) above, the
Holder, after receipt of the determination by the Appraiser, shall have the
right to select an additional appraiser (which shall be a nationally recognized
accounting firm), in which case the adjustment shall be equal to the average of
the adjustments recommended by each of the Appraiser and such additional
appraiser

 

 

appointed under this subsection (g). The Holder shall promptly mail or cause to
be mailed to the Company, a notice setting forth the Exercise Price after such
adjustment and setting forth a brief statement of the facts requiring such
adjustment. Such adjustment shall become effective immediately after the record
date mentioned above, if:

 

(i)the Company shall declare a dividend (or any other distribution) on its
Common Stock; or

 

(ii)the Company shall declare a special nonrecurring cash dividend on or a
redemption of its Common Stock; or

 

(iii)the Company shall authorize the granting to all holders of the Common Stock
rights or warrants to subscribe for or purchase any shares of capital stock of
any class or of any rights; or

 

(iv)the approval of any stockholders of the Company shall be required in
connection with any reclassification of the Common Stock of the Company, any
consolidation or merger to which the Company is a party, any sale or transfer of
all or substantially all of the assets of the Company, or any compulsory share
exchange whereby the Common Stock is converted into other securities, cash or
property; or

 

(v)the Company shall authorize the voluntary dissolution, liquidation or winding
up of the affairs of the Company, then the Company shall cause to be mailed to
the Holder at their last addresses as they shall appear upon the Warrant
Register, at least 30 calendar days prior to the applicable record or effective
date hereinafter specified, a notice stating (x) the date on which a record is
to be taken for the purpose of such dividend, distribution, redemption, rights
or warrants, or if a record is not to be taken, the date as of which the holders
of Common Stock of record to be entitled to such dividend, distributions,
redemption, rights or warrants are to be determined or (y) the date on which
such reclassification, consolidation, merger, sale, transfer or share exchange
is expected to become effective or close, and the date as of which it is
expected that holders of Common Stock of record shall be entitled to exchange
their shares of Common Stock for securities, cash or other property deliverable
upon such reclassification, consolidation, merger, sale, transfer, share
exchange, dissolution, liquidation or winding up; provided, however, that the
failure to mail such notice or any defect therein or in the mailing thereof
shall not affect the validity of the corporate action required to be specified
in such notice.

 

9. Payment of Shares. The Holder shall deliver cash funds to the Company within
five days of exercising any amount of this Warrant. The Holder is limited in the
amount of this Warrant it may exercise. In no event shall the Holder be entitled
to exercise any amount of this Warrant in excess of that amount upon exercise of

 

 

which the sum of (1) the number of shares of Common Stock beneficially owned (as
such term is defined under Section 13(d) and Rule 13d-3 of the Securities
Exchange Act of 1934 (the 1934 Act”)) by the Holder, and (2) the number of
Warrant Shares issuable upon the exercise of any Warrants then owned by Holder,
would result in beneficial ownership by the Holder of more than 9.9% of the
outstanding shares of Common Stock of the Company, as determined in accordance
with Rule13d-1(j). Furthermore, the Company shall not process any exercise that
would result in beneficial ownership by the Holder of more than 9.9% of the
outstanding shares of Common Stock of the Company.

 

10. Fractional Shares. The Company shall not be required to issue or cause to be
issued fractional Warrant Shares on the exercise of this Warrant. The number of
full Warrant Shares which shall be issuable upon the exercise of this Warrant
shall be computed on the basis of the aggregate number of Warrant Shares
purchasable on exercise of this Warrant so presented. If any fraction of a
Warrant Share would, except for the provisions of this Section 10, be issuable
on the exercise of this Warrant, the Company shall pay an amount in cash equal
to the Exercise Price multiplied by such fraction.

 

11. Notices. Any and all notices or other communications or deliveries hereunder
shall be in writing and shall be deemed given and effective on the earliest of
(i) the date of transmission, if such notice or communication is delivered via
facsimile at the facsimile telephone number specified in this Section prior to
5:00 p.m. (Boston time) on a business day, (ii) the business day after the date
of transmission, if such notice or communication is delivered via facsimile at
the facsimile telephone number specified in this Section later than 5:00 p.m.
(Boston time) on any date and earlier than 11:59 p.m. (Boston time) on such
date, (iii) the business day following the date of mailing, if sent by
nationally recognized overnight courier service, or (iv) upon actual receipt by
the party to whom such notice is required to be given. The addresses for such
communications shall be: (i) if to the Company, to:

 

 

NatureWell, Incorporated

Attention: T. Psomiadis

151 W. Passaic Street

Rochelle Park, NJ 07662

 

 

or (ii) if to the Holder, to the Holder at the address or facsimile number
appearing on the Warrant Register or such other address or facsimile number as
the Holder may provide to the Company in accordance with this Section 11.

 

12. Warrant Agent. The Company shall serve as warrant agent under this Warrant
Agreement. Upon thirty (30) days notice to the Holder, the Company may appoint a
new warrant agent. Any corporation into which the Company or any new warrant
agent may be merged or any corporation resulting from any consolidation to which
the Company or any new warrant agent shall be a party or any corporation to
which the Company or any new warrant agent transfers substantially all of its
corporate

 

 

trust or shareholders services business shall be a successor warrant agent under
this Warrant without any further act. Any such successor warrant agent shall
promptly cause notice of its succession as warrant agent to be mailed (by first
class mail, postage prepaid) to the Holder at the Holder's last address as shown
on the Warrant Register.

 

13. Miscellaneous.

 

(a) This Warrant Agreement shall be binding on and inure to the benefit of the
parties hereto. This Warrant may be amended only in writing signed by the
Company and the Holder.

 

(b) Nothing in this Warrant shall be construed to give to any person or
corporation other than the Company and the Holder any legal or equitable right,
remedy or cause under this Warrant. This Warrant shall inure to the sole and
exclusive benefit of the Company and the Holder.

 

(c) This Warrant shall be governed by and construed and enforced in accordance
with the laws of the State of Delaware without regard to the principles of
conflicts of law thereof.

 

(d) The headings herein are for convenience only, do not constitute a part of
this Warrant and shall not be deemed to limit or affect any of the provisions
hereof.

 

(e) In case any one or more of the provisions of this Warrant shall be invalid
or unenforceable in any respect, the validity and enforceability of the
remaining terms and provisions of this Warrant shall not in any way be affected
or impaired thereby and the parties will attempt in good faith to agree upon a
valid and enforceable provision which shall be a commercially reasonable
substitute therefor, and upon so agreeing, shall incorporate such substitute
provision in this Warrant.

 

14. Disputes Under This Agreement.

 

All disputes arising under this agreement shall be governed by and interpreted
in accordance with the laws of the State of Delaware, without regard to
principles of conflict of laws. The parties to this agreement will submit all
disputes arising under this agreement to arbitration in Boston, Commonwealth of
Massachusetts before a single arbitrator of the American Arbitration Association
(“AAA”). The arbitrator shall be selected by application of the rules of the
AAA, or by mutual agreement of the parties, except that such arbitrator shall be
an attorney admitted to practice law in the Commonwealth of Massachusetts. No
party to this agreement will challenge the jurisdiction or venue provisions as
provided in this section.

 

Nothing in this section shall limit the Holder's right to obtain an injunction
for a breach of this Agreement from a court of law.

 

 

 

IN WITNESS WHEREOF, the Company has caused this Warrant to be duly executed by
its authorized officer as of the date first indicated above.

 

 

 

Naturewell, incorporated

 

By: ____________________

Name: Themistocles Psomiadis

Title: Chief Executive Officer

 

 

 

 

 

 

 

 

 

EXHIBIT A FORM OF ELECTION TO PURCHASE

 

(To be executed by the Holder to exercise the right to purchase shares of Common
Stock under the foregoing Warrant)

 

To: Brazil Interactive Media, Inc. (f/k/a NatureWell, Incorporated)

 

In accordance with the Warrant enclosed with this Form of Election to Purchase,
the undersigned hereby irrevocably elects to purchase _____________ shares of
Common Stock ("Common Stock"), $0.0001 par value per share, of Brazil
Interactive Media, Inc.(f/k/a NatureWell, Incorporated) encloses herewith
$________ in cash, certified or official bank check or checks, which sum
represents the aggregate Exercise Price (as defined in the Warrant) for the
number of shares of Common Stock to which this Form of Election to Purchase
relates, together with any applicable taxes payable by the undersigned pursuant
to the Warrant.

 

The undersigned requests that certificates for the shares of Common Stock
issuable upon this exercise be issued in the name of

 

 

PLEASE INSERT SOCIAL SECURITY OR

TAX IDENTIFICATION NUMBER

 

_________________________________________

 

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(Please print name and address)

 

If the number of shares of Common Stock issuable upon this exercise shall not be
all of the shares of Common Stock which the undersigned is entitled to purchase
in accordance with the enclosed Warrant, the undersigned requests that a New
Warrant (as

 

 

 

defined in the Warrant) evidencing the right to purchase the shares of Common
Stock not issuable pursuant to the exercise evidenced hereby be issued in the
name of and delivered to:

 

 

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(Please print name and address)

 

 

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Dated:     Name of Holder:

(Print)____________________________________

 

(By:)_____________________________________

(Name:)

(Title:)

 

(Signature must conform in all respects to name of holder as specified on the
face of the Warrant)