Exhibit 10.02
 
NEITHER THIS SECURITY NOR THE SECURITIES FOR WHICH THIS SECURITY 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. THIS SECURITY AND THE SECURITIES ISSUABLE UPON EXERCISE OF THIS
SECURITY MAY BE PLEDGED IN CONNECTION WITH A BONA FIDE MARGIN ACCOUNT OR OTHER
LOAN SECURED BY SUCH SECURITIES.
 
 
CHROMADEX CORPORATION
 
Warrant No.:__________
 
Initial Exercise Date: March ___, 2016
   
Issuance Date:  March ___,  2016

 
Number of American Transfer Agent   Shares: ________________
 
THIS WARRANT TO PURCHASE COMMON STOCK (the “Warrant”) certifies that, for value
received, _____________ or its assigns (the “Holder”) is entitled, upon the
terms and subject to the limitations on exercise and the conditions hereinafter
set forth, at any time on or after March ___, 2016 (the “Initial Exercise Date”)
and on or prior to the close of business on the third year anniversary of the
Initial Exercise Date (the “Termination Date”) but not thereafter, to subscribe
for and purchase from Chromadex Corporation, a corporation incorporated under
the laws of the state of Delaware (the “Company”), up to 192,308 shares of
Common Stock (the “Warrant Shares”), as subject to adjustment hereunder. The
purchase price of one Warrant Share shall be equal to the Exercise Price, as
defined in Section 2(b).
 
Section 1. Definitions. Capitalized terms used and not otherwise defined herein
shall have the meanings set forth in that certain Securities Purchase Agreement
(the “Purchase Agreement”), dated March __, 2016, among the Company and the
purchasers signatory thereto. 
 
Section 2.            Exercise.
 
a)            Exercise of Warrant. Provided that the Warrant Shares may be sold
pursuant to the registration requirements of the Securities Act, including any
applicable prospectus delivery requirements, or an exemption from the
registration requirements of the Securities Act is available to Holder, exercise
of the purchase rights represented by this Warrant may be made, in whole or in
part, at any time or times on or after the Initial Exercise Date and on or
before the Termination Date by delivery to the Company (or such other office or
agency of the Company as it may designate by notice in writing to the registered
Holder at the address of the Holder appearing on the books of the Company) and
the Transfer Agent   of a duly executed facsimile copy (or .pdf copy via e-mail)
of the Notice of Exercise in the form annexed hereto and within three (3)
Trading Days of the date said Notice of Exercise is delivered to the Company,
the Company shall have received payment of the aggregate Exercise Price of the
Warrant Shares thereby purchased by wire transfer or cashier’s check drawn on a
United States bank. No ink-original Notice of Exercise shall be required, nor
shall any medallion guarantee (or other type of guarantee or notarization) of
any Notice of Exercise form be required. Notwithstanding anything herein to the
contrary, the Holder shall not be required to physically surrender this Warrant
to the Company until the Holder has purchased all of the Warrant Shares
available hereunder and the Warrant has been exercised in full, in which case,
the Holder shall surrender this Warrant to the Company for cancellation within
three (3) Trading Days of the date the final Notice of Exercise is delivered to
the Company. Partial exercises of this Warrant resulting in purchases of a
portion of the total number of Warrant Shares available hereunder shall have the
effect of lowering the outstanding number of Warrant Shares purchasable
hereunder in an amount equal to the

 
-1-

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

 
 
applicable number of Warrant Shares purchased. The Holder and the Company shall
maintain records showing the number of Warrant Shares purchased and the date of
such purchases. The Company shall deliver any objection to any Notice of
Exercise within two (2) Business Days of receipt of such notice. The Holder and
any assignee, by acceptance of this Warrant, acknowledge and agree that, by
reason of the provisions of this paragraph, following the purchase of a portion
of the Warrant Shares hereunder, the number of Warrant Shares available for
purchase hereunder at any given time may be less than the amount stated on the
face hereof.  The Holder and any assignee, by acceptance of this Warrant,
further acknowledge and agree that in no event shall the Company be required to
issue any Warrant Shares unless (i) the Warrant Shares may be sold pursuant to
the registration requirements of the Securities Act, including any applicable
prospectus delivery requirements, or (ii) a valid exemption to the registration
requirements of the Securities Act is available to Holder, and in no event shall
Holder be required to pay Company any penalty in connection with failure to
issue Warrant Shares due to the absence of the foregoing conditions.  
 
b)            Exercise Price. The exercise price per Warrant Share under this
Warrant shall be $1.60, subject to adjustment hereunder (the “Exercise Price”).
 
c)            Reserved.
 
d)            Mechanics of Exercise.
 
i.            Delivery of Warrant Shares Upon Exercise. Within three (3) Trading
Days of the date that a Notice of Exercise is delivered to the Company in
accordance with the foregoing provisions, certificates for Warrant Shares
purchased hereunder shall be transmitted by the Transfer Agent to the Holder by
crediting the account of the Holder’s prime broker with The Depository Trust
Company through its Deposit or Withdrawal at Custodian system (“DWAC”) if the
Company is then a participant in such system and there is an effective
registration statement permitting the resale of the Warrant Shares by the Holder
or otherwise by physical delivery to the address specified by the Holder in the
Notice of Exercise by the date that is three (3) Trading Days after the latest
of (A) the delivery to the Company of the Notice of Exercise, (B) surrender of
this Warrant (if required) and (C) payment of the aggregate Exercise Price. The
Warrant Shares shall be deemed to have been issued, and Holder or any other
person so designated to be named therein shall be deemed to have become a holder
of record of such shares for all purposes, as of the date the Warrant has been
exercised, with payment to the Company of the Exercise Price and all taxes
required to be paid by the Holder, if any, pursuant to Section 2(d)(vi) prior to
the issuance of such shares, having been paid.
 
ii.            Delivery of New Warrants Upon Exercise. If this Warrant shall
have been exercised in part, the Company shall, at the request of a Holder and
upon surrender of this Warrant certificate, at the time of delivery of the
Warrant Shares, deliver to the Holder a new Warrant evidencing the rights of the
Holder to purchase the unpurchased Warrant Shares called for by this Warrant,
which new Warrant shall in all other respects be identical with this Warrant.
 
iii.           Reserved.
 
iv.           Reserved. 
 
v.              No Fractional Shares or Scrip. No fractional Warrant Shares
shall be issued upon the exercise of this Warrant. As to any fraction of a
Warrant Share which the Holder would otherwise be entitled to purchase upon such
exercise, the Company shall, at its election, either pay a cash adjustment in
respect of such final fraction in an amount equal to such fraction multiplied by
the Exercise Price or round up to the next whole share.

 
-2-

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

 
 
vi.             Charges, Taxes and Expenses. Issuance of Warrant Shares shall be
made without charge to the Holder for any issue or transfer tax or other
incidental expense in respect of the issuance of Warrant Shares, all of which
taxes and expenses shall be paid by the Company, and such Warrant Shares shall
be issued in the name of the Holder or in such name or names as may be directed
by the Holder; provided, however, that in the event that Warrant Shares are to
be issued in a name other than the name of the Holder, this Warrant when
surrendered for exercise shall be accompanied by the Assignment Form attached
hereto duly executed by the Holder and the Company may require, as a condition
thereto, the payment of a sum sufficient to reimburse it for any transfer tax
incidental thereto. The Company shall pay all Transfer Agent   fees required for
same-day processing of any Notice of Exercise.
 
vii.             Closing of Books. The Company will not close its shareholder
books or records in any manner which prevents the timely exercise of this
Warrant, pursuant to the terms hereof.
 
e)             Holder’s Exercise Limitations. Notwithstanding anything herein to
the contrary, the Company shall not effect the exercise of this Warrant, and the
Holder shall not have the right to exercise this Warrant, to the extent that,
after giving effect to such exercise, such Person (together with such Person's
affiliates, and any other Person whose beneficial ownership of Common Stock
would be aggregated with the Holder’s for purposes of Section 13(d) of the
Securities Exchange Act of 1934, as amended (the “Exchange Act”), and the
applicable rules and regulations of the Securities and Exchange Commission (the
“SEC”), including any “group” of which the Holder is a member) would
beneficially own a number of shares of Common Stock in excess of the Beneficial
Ownership Limitation (as defined below). For purposes of the foregoing sentence,
the aggregate number of shares of Common Stock beneficially owned by such Person
and its affiliates shall include the number of shares of Common Stock issuable
upon exercise of this Warrant with respect to which the determination of such
sentence is being made, but shall exclude the number of shares of Common Stock
which are issuable upon (i) exercise of the remaining, unexercised portion of
this Warrant beneficially owned by such Person and its affiliates and (ii)
exercise or conversion of the unexercised or unconverted portion of any other
securities of the Company beneficially owned by such Person and its affiliates
(including, without limitation, any convertible notes, convertible stock or
warrants) that are subject to a limitation on conversion or exercise analogous
to the limitation contained herein. Except as set forth in the preceding
sentence, for purposes of this Section 1(g), beneficial ownership shall be
calculated in accordance with Section 13(d) of the Exchange Act, and the
applicable rules and regulations of the SEC. In addition, for purposes hereof,
“group” has the meaning set forth in Section 13(d) of the Exchange Act and the
applicable rules and regulations of the SEC. For purposes of this Warrant, in
determining the number of outstanding shares of Common Stock, the Holder may
rely on the number of outstanding shares of Common Stock as reflected in (1) the
Company's most recent Form 10-K, Form 10-Q, Current Report on Form 8-K or other
public filing with the SEC, as the case may be, (2) a more recent public
announcement by the Company or (3) a more recent notice by the Company or the
Transfer Agent to the Holder setting forth the number of shares of Common Stock
then outstanding. For any reason at any time, upon the written or oral request
of the Holder, the Company shall, within two (2) Business Days of such request,
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 any actual conversion or exercise of
securities of the Company, including this Warrant, by the Holder and its
affiliates since the date as of which such number of outstanding shares of
Common Stock was last publicly reported or confirmed to the Holder. The
“Beneficial Ownership Limitation” shall be 4.99% of the number of shares of the
Common Stock outstanding immediately after giving effect to the issuance of
shares of Common Stock pursuant to such Exercise Notice (to the extent permitted
pursuant to this Section 2(e)). If the Holder has delivered an Exercise Notice,
the Company shall be entitled to assume that such exercise will not result in
the Holder exceeding the Beneficial Ownership Limitation as a result of the
exercise contemplated by such Exercise Notice. The provisions of this Section
2(e) shall be construed, corrected and implemented in a manner so as to
effectuate the intended beneficial ownership limitation herein contained.

 
-3-

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

 
 
Section 3.          Certain Adjustments.
 
a)           Share Dividends and Splits.  If the Company at any time on or after
the Issuance Date subdivides (by any stock split, stock dividend,
recapitalization, reorganization, scheme, arrangement or otherwise) one or more
classes of its outstanding shares of Common Stock into a greater number of
shares, the Exercise Price in effect immediately prior to such subdivision will
be proportionately reduced and the number of Warrant Shares will be
proportionately increased. If the Company at any time on or after the Issuance
Date combines (by any stock split, stock dividend, recapitalization,
reorganization, scheme, arrangement or otherwise) one or more classes of its
outstanding shares of Common Stock into a smaller number of shares, the Exercise
Price in effect immediately prior to such combination will be proportionately
increased and the number of Warrant Shares will be proportionately decreased.
Any adjustment under this Section 3(a) shall become effective at the close of
business on the date the subdivision or combination becomes effective
 
b)           Fundamental Transactions.  If the Company enters into or becomes a
party to any Fundamental Transaction, then the registered holder shall have the
right thereafter to receive, upon exercise of the Warrant, the same amount and
kind of securities, cash or property as it would have been entitled to receive
upon the occurrence of such Fundamental Transaction if it had been, immediately
prior to such Fundamental Transaction, the holder of the number of Warrant
Shares then issuable upon exercise in full of the Warrant without regard to any
limitations on exercise contained in the Warrant (the “Alternate
Consideration”). The Company shall not effect any such Fundamental Transaction
unless prior to or simultaneously with the consummation thereof, any successor
to the Company, surviving entity or the corporation purchasing or otherwise
acquiring such assets or other appropriate corporation or Person shall assume
the Warrant and the obligation to deliver to the registered holder, such
Alternate Consideration as, in accordance with the foregoing provisions, the
registered holder may be entitled to receive, and the other obligations under
the Warrant.  “Fundamental Transactions” means that (i) the Company or any of
its Subsidiaries shall, directly or indirectly, in one or more related
transactions, (1) consolidate or merge with or into (whether or not the Company
or any of its Subsidiaries is the surviving corporation) any other person unless
immediately following the closing of such transaction or series of related
transactions the persons holding more than 50% of the voting stock of the
Company prior to such closing continue to hold more than 50% of the voting stock
of the Company following such closing or (2) sell, lease, license, assign,
transfer, convey or otherwise dispose of all or substantially all of its
respective properties or assets to any other person, or (3) assist any other
person in making a purchase, tender or exchange offer that is accepted by the
holders of more than 50% of the outstanding shares of voting stock of the
Company (not including any shares of voting stock of the Company held by the
person or persons making or party to, or associated or affiliated with the
persons making or party to, such purchase, tender or exchange offer), or (4)
consummate a stock or share purchase agreement or other business combination
(including, without limitation, a reorganization, recapitalization, or scheme of
arrangement) with any other person whereby such other person acquires more than
50% of the outstanding shares of Voting Stock of the Company (not including any
shares of voting stock of the Company held by the other person or other persons
making or party to, or associated or affiliated with the other persons making or
party to, such stock or share purchase agreement or other business combination)
excluding any equity financing transaction in which shares of voting stock are
issued, or (5) (I) reorganize, recapitalize or reclassify the Common Stock, (II)
effect or consummate a stock combination, reverse stock split or other similar
transaction involving the Common Stock or (III) make any public announcement or
disclosure with respect to any stock combination, reverse stock split or other
similar transaction involving the Common Stock (including, without limitation,
any public announcement or disclosure of (x) any potential, possible or actual
stock combination, reverse stock split or other similar transaction involving
the Common Stock or (y) board or stockholder approval thereof, or the intention
of the Company to seek board or stockholder approval of any stock combination,
reverse stock split or other similar transaction involving the Common Stock), or
(ii) any “person” or “group” (as these terms are used for purposes of Sections
13(d) and 14(d) of the Exchange Act and the rules and regulations promulgated
thereunder) is or shall become the “beneficial owner” (as defined in Rule 13d-3
under the Exchange Act), directly or indirectly, of 50% of the aggregate
ordinary voting power represented by issued and outstanding voting stock of the
Company.   

 
-4-

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

 
 
c)        Calculations. All calculations under this Section 3 shall be made to
the nearest cent or the nearest 1/100th of a Warrant Share, as the case may be.
 
d)           Notice to Holder.  Whenever the Exercise Price is adjusted pursuant
to any provision of this Section 3, the Company shall promptly mail to the
Holder a notice setting forth the Exercise Price after such adjustment and any
resulting adjustment to the number of Warrant Shares and setting forth a brief
statement of the facts requiring such adjustment.
 

Section 4.          Transfer of Warrant.
 
a)           Transferability. Subject to compliance with any applicable
securities laws and the conditions set forth in Section 4(d) hereof and to the
provisions of Section 4.6 of the Purchase Agreement, this Warrant and all rights
hereunder are transferable, in whole or in part, upon surrender of this Warrant
at the principal office of the Company or its designated agent, together with a
written assignment of this Warrant substantially in the form attached hereto
duly executed by the Holder or its agent or attorney and funds sufficient to pay
any transfer taxes payable upon the making of such transfer. Upon such surrender
and, if required, such payment, the Company shall execute and deliver a new
Warrant or Warrants in the name of the assignee or assignees, as applicable, and
in the denomination or denominations specified in such instrument of assignment,
and shall issue to the assignor a new Warrant evidencing the portion of this
Warrant not so assigned, and this Warrant shall promptly be cancelled.
Notwithstanding anything herein to the contrary, the Holder shall not be
required to physically surrender this Warrant to the Company unless the Holder
has assigned this Warrant in full, in which case, the Holder shall surrender
this Warrant to the Company within three (3) Trading Days of the date the Holder
delivers an assignment form to the Company assigning this Warrant full. The
Warrant, if properly assigned in accordance herewith, may be exercised by a new
holder for the purchase of Warrant Shares without having a new Warrant issued.
 
b)           New Warrants. This Warrant may be divided or combined with other
Warrants upon presentation hereof at the aforesaid office of the Company,
together with a written notice specifying the names and denominations in which
new Warrants are to be issued, signed by the Holder or its agent or attorney.
Subject to compliance with Section 4(a), as to any transfer which may be
involved in such division or combination, the Company shall execute and deliver
a new Warrant or Warrants in exchange for the Warrant or Warrants to be divided
or combined in accordance with such notice. All Warrants issued on transfers or
exchanges shall be dated the Initial Exercise Date and shall be identical with
this Warrant except as to the number of Warrant Shares issuable pursuant
thereto.
 
c)           Warrant Register. 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, absent actual notice to the contrary.
 
d)          Transfer Restrictions. If, at the time of the surrender of this
Warrant in connection with any transfer of this Warrant, the transfer of this
Warrant shall not be either (i) registered pursuant to an effective registration
statement under the Securities Act and under applicable state securities or blue
sky laws or (ii) eligible for resale without volume or manner-of-sale
restrictions or current public information requirements pursuant to Rule 144,
the Company shall require, as a condition of allowing such transfer, that the
Holder or transferee of this Warrant, as the case may be, comply with the
provisions of the Purchase Agreement, including Section 4.6 thereof.
 
e)           Representation by the Holder. The Holder, by the acceptance hereof,
represents and warrants that it is acquiring this Warrant and, upon any exercise
hereof, will acquire the Warrant Shares issuable upon such exercise, for its own
account and not with a view to or for distributing or reselling such Warrant
Shares or any part thereof in violation of the Securities Act or any applicable
state securities law, except pursuant to sales registered or exempted under the
Securities Act.
 
 
-5-

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

 
 
Section 5.          Miscellaneous.
 
a)           Reserved.

 b)           No Rights as Shareholder Until Exercise. This Warrant does not
entitle the Holder to any voting rights, dividends or other rights as a
shareholder of the Company prior to the exercise hereof, except as expressly set
forth in Section 3.
 
c)           Loss, Theft, Destruction or Mutilation of Warrant. The Company
covenants that upon receipt by the Company of evidence reasonably satisfactory
to it of the loss, theft, destruction or mutilation of this Warrant or any stock
certificate relating to the Warrant Shares, and in case of loss, theft or
destruction, of indemnity or security reasonably satisfactory to it (which, in
the case of the Warrant, shall not include the posting of any bond), and upon
surrender and cancellation of such Warrant or stock certificate, if mutilated,
the Company will make and deliver a new Warrant or stock certificate of like
tenor and dated as of such cancellation, in lieu of such Warrant or stock
certificate.
 
d)           Saturdays, Sundays, Holidays, etc. If the last or appointed day for
the taking of any action or the expiration of any right required or granted
herein shall not be a Business Day, then, such action may be taken or such right
may be exercised on the next succeeding Business Day.
 
e)           Reserved.
 
f)            Jurisdiction. All questions concerning the construction, validity,
enforcement and interpretation of this Warrant shall be determined in accordance
with the provisions of the Purchase Agreement.
 
g)           Restrictions. The Holder acknowledges that the Warrant Shares
acquired upon the exercise of this Warrant, if not registered, will have
restrictions upon resale imposed by state and federal securities laws.
 
h)          Nonwaiver and Expenses. No course of dealing or any delay or failure
to exercise any right hereunder on the part of Holder shall operate as a waiver
of such right or otherwise prejudice the Holder’s rights, powers or remedies,
notwithstanding the fact that all rights hereunder terminate on the Termination
Date. If the Company willfully and knowingly fails to comply with any provision
of this Warrant, which results in any material damages to the Holder, the
Company shall pay to the Holder such amounts as shall be sufficient to cover any
costs and expenses including, but not limited to, reasonable attorneys’ fees,
including those of appellate proceedings, incurred by the Holder in collecting
any amounts due pursuant hereto or in otherwise enforcing any of its rights,
powers or remedies hereunder.
  
i)            Notices. Any notice, request or other document required or
permitted to be given or delivered to the Holder by the Company shall be
delivered in accordance with the notice provisions of the Purchase Agreement.
 
j)            Successors and Assigns. Subject to applicable securities laws,
this Warrant and the rights and obligations evidenced hereby shall inure to the
benefit of and be binding upon the successors and permitted assigns of the
Company and the successors and permitted assigns of Holder. The provisions of
this Warrant are intended to be for the benefit of any Holder from time to time
of this Warrant and shall be enforceable by the Holder or holder of Warrant
Shares.
 
k)          Amendment. This Warrant may be modified or amended or the provisions
hereof waived with the written consent of the Company and the Holder.
 
 
-6-

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

 
 
l)           Severability. Wherever possible, each provision of this Warrant
shall be interpreted in such manner as to be effective and valid under
applicable law, but if any provision of this Warrant shall be prohibited by or
invalid under applicable law, such provision shall be ineffective to the extent
of such prohibition or invalidity, without invalidating the remainder of such
provisions or the remaining provisions of this Warrant.
 
m)           Headings. The headings used in this Warrant are for the convenience
of reference only and shall not, for any purpose, be deemed a part of this
Warrant.
 
********************
 
(Signature Page Follows)

 
-7-

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

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

 
CHROMADEX CORPORATION
 
 
By:
     
Name:
   
Title:

 

 
-8-

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

 
 
NOTICE OF EXERCISE
 
TO:         
CHROMADEX CORPORATION
 
THE EQUITY STOCK TRANSFER LLC

 
(1)   The undersigned hereby elects to purchase ________ Warrant Shares of the
Company pursuant to the terms of the attached Warrant (only if exercised in
full), and tenders herewith payment of the exercise price in full, together with
all applicable transfer taxes, if any.
 
(2)   Payment shall take the form of lawful money of the United States.
 
(3)   Please register and issue said Warrant Shares in the name of the
undersigned or in such other name as is specified below:

[A]
 
DTC Participant name and number: ________________________
Contact of DTC Participant: _______________________
Telephone Number of Participant Contact: _____________________

or

[B]
 
Holder’s name: ________________________
Holder’s address: _______________________
Telephone Number: _____________________

 
(4)   Accredited Investor. The undersigned is an “accredited investor” as
defined in Regulation D promulgated under the Securities Act of 1933, as
amended.
 
 
[SIGNATURE OF HOLDER]
 
Name of Investing Entity:
________________________________________________________________________
Signature of Authorized Signatory of Investing Entity:
_________________________________________________
Name of Authorized Signatory:
___________________________________________________________________
Title of Authorized Signatory:
____________________________________________________________________
Date:
________________________________________________________________________________________
  

 
-9-

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

 
 
EXHIBIT B
 
ASSIGNMENT FORM
 
(To assign the foregoing Warrant, execute this form and supply required
information. Do not use this form to purchase Warrant Shares.)
 
FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are
hereby assigned to
 
Name:
       
(Please Print)
Address:
       
(Please Print)
Dated: _______________ __, ______
   
Holder’s Signature:  ______________________________
   
Holder’s Address:    ______________________________
   

 
 
-10-

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