EX-4.1



 Exhibit 4.1 

 

 



 


 



 
  

			
	



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	 Computershare Trust Company, N.A.        

250 Royall Street        

Canton Massachusetts 02021        
	 		 	

  
 



 
  

			
	Primary Subscription Rights	  	12345678901234

 
 


	
	  

PRESBIA PLC SUBSCRIPTION RIGHTS OFFERING
  


 THIS SUBSCRIPTION RIGHTS OFFERING EXPIRES AT <TIME>, <TIME ZONE>, ON <DATE>, UNLESS THE EXERCISE PERIOD IS
EXTENDED (SUCH DATE AND TIME, AS IT MAY BE EXTENDED, THE “EXPIRATION DATE”). 
 Presbia PLC has distributed to each holder of its ordinary
shares owned as of record (each an “Eligible Holder”) at <TIME> on <DATE> (the “Record Date”), at no charge, one non-transferable,
non-exchangeable right for each ordinary share held as of the Record Date, to purchase <NUMBER> of an ordinary shares of Presbia PLC at <$AMOUNT> per full share (the “Subscription
Rights”). Each Subscription Right entitles an Eligible Holder who fully exercises its basic subscription privilege to subscribe, prior to the Expiration Date, for additional ordinary shares of Presbia PLC at an exercise price of <$AMOUNT>
per full share to the extent that any shares are not purchased by other Eligible Holders under their basic subscription privilege as of the Expiration Date or to the extent Presbia PLC decides to increase the size of the offering (the
“Oversubscription Privilege”). The terms and conditions of the Subscription Rights offering are set forth in Presbia PLC’s Prospectus dated <DATE> (as it may be amended or supplemented, the “Prospectus”), which is
incorporated into this Rights Certificate by reference. Capitalized terms used but not defined herein have the meanings set forth in the Prospectus. Presbia PLC hereby undertakes and confirms by the issuance of this certificate to Eligible Holders
that the owner of this certificate is entitled to the number of basic Subscription Rights, and is entitled to exercise the basic Subscription Rights for the number of shares, shown on this Rights Certificate and that the Subscription Rights are
legal, valid and binding obligations of Presbia PLC subject to the terms and conditions of the Subscription Rights offering set forth in the Prospectus. 

THE SUBSCRIPTION RIGHTS ARE NON-TRANSFERABLE AND
NON-EXCHANGEABLE 
 The Subscription Rights are non-transferable and non-exchangeable. The Subscription Rights will not be listed on any securities exchange or quoted on any automated quotation system. Presbia PLC cannot assure you that any ordinary shares of Presbia PLC issued in
respect of exercised Subscription Rights will ever be listed on the New York Stock Exchange, the Nasdaq Global Select Market or any other securities exchange or quotation system. 

EXERCISE PRICE 
 The exercise price for
the Subscription Rights and the Oversubscription Privilege is <$AMOUNT> per full share. A fractional Subscription Right will not be exercisable unless it is aggregated with other fractional Subscription Rights so that when exercised, in the
aggregate, such fractional Subscription Rights result in the purchase of a whole ordinary share of Presbia PLC. In other words, fractional Subscription Rights cannot be exercised for fractional ordinary shares of Presbia PLC. 

METHOD OF EXERCISE OF RIGHTS 
 IN ORDER
TO EXERCISE YOUR SUBSCRIPTION RIGHTS, YOU MUST PROPERLY COMPLETE AND SIGN THIS RIGHTS CERTIFICATE ON THE BACK AND RETURN IT IN THE ENVELOPE PROVIDED TO COMPUTERSHARE TRUST COMPANY, N.A., TOGETHER WITH PAYMENT IN FULL FOR AN AMOUNT EQUAL TO THE
APPLICABLE EXERCISE PRICE MULTIPLIED BY THE TOTAL NUMBER OF ORDINARY SHARES THAT YOU ARE REQUESTING TO PURCHASE TO THE RIGHTS AGENT, COMPUTERSHARE TRUST COMPANY, N.A., BEFORE <TIME>, ON <DATE>. 

 

											
	Holder ID	  	COY	  	Class	  	Rights Qty Issued	  	Rights Cert #	  	
	123456789	  	XXXX	  	Subscription Rights	  	XXX.XXXXXX	  	12345678	  	

  

									
	 Signature of Owner and U.S. Person for Tax Certification
  
	 		 	 Signature of Co-Owner (if more than one registered holder listed)

 
	 		 	 Date (mm/dd/yyyy)
  

	 	 		 	 	 		 	 
	 	 		 	 	 		 	 
	 	 		 	 	 		 	 

  
 



 
 02HNJD 







 Full payment of the exercise price for each ordinary share you wish to purchase must be made in U.S. dollars by
(1) personal check drawn upon a U.S. bank payable to the Rights Agent, or (2) bank draft drawn upon a U.S. bank payable to the Rights Agent, in each case in accordance with the “Instructions As To Use of Presbia PLC Subscription
Rights Certificates” that accompanied the mailing of the Prospectus. Notwithstanding the foregoing, Eligible Holders who hold shares as a depository or nominee must make all payments by wire transfer of immediately available funds to the
account maintained by the Rights Agent. 
 Payments of the exercise price for the ordinary shares will be held in an account until five business days
following the Expiration Date, unless Presbia PLC withdraws or terminates the Subscription Rights offering. No interest will be paid to you on the funds you deposit with the Rights Agent. You will not receive any interest on the payments held by the
Rights Agent before your shares have been issued to you or your payment is returned to you, without interest, because your exercise has not been satisfied for any reason. 

 

PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY 

 

																			
	
	SECTION 1:         OFFERING INSTRUCTIONS (check the appropriate boxes)
	 IF YOU WISH TO SUBSCRIBE FOR YOUR FULL ENTITLEMENT OF SUBSCRIPTION RIGHTS:

 

	☐	 	I apply for ALL of my entitlement of new shares pursuant to the basic subscription	 		 	  
	 	        x <XXX> =    	 	  
	 	        x <$AMOUNT> =    	 		 	$	 	
                 


		 	 		 	(no. of subscription rights)	 	 	(no. of new shares)	 	(per share)	 		 		 	
		 	  
 EXAMPLE: If you own 1,000 ordinary shares, your basic
subscription right permits the purchase of XXX shares. [1,000 purchase rights / XXX = XXX with fractional shares rounded down to the nearest whole number].
	 		 		 		 	

  

																	
	☐	 	In addition, I apply for additional shares pursuant to the Oversubscription Privilege*	 		 	  
	 	x <$AMOUNT> =	 	$	 	              

		 	 		 	(no. of additional shares)	 	(per share)	 		 	
	  
 IF YOU DO NOT WISH TO APPLY FOR YOUR FULL ENTITLEMENT OF
SUBSCRIPTION RIGHTS:
  
	 		 		 		 	
	☐	 	I apply for	 		 	  
	 	x <$AMOUNT> =	 	$	 	
                 


		 		 		 	(no. of new shares)	 	(per share)	 		 	
						
		 	Amount of check or money order enclosed    	 		 		 		 	
		 		 		 		 		 		 		 	$	 	              


  

	
	 IF YOU DO NOT WISH TO EXERCISE YOUR RIGHT TO SUBSCRIBE:

Please disregard this mailing.



 

					
		
	SECTION 2:         SUBSCRIPTION AUTHORIZATION:	  	
	
	 I acknowledge that I have received the Prospectus for this offering of Subscription Rights and I hereby
subscribe for the number of shares indicated above on the terms and conditions specified in the Prospectus relating to the basic subscription and the Oversubscription Privilege in the Subscription Rights offering.


  

					
	Signature of Subscriber(s)	 		  	
	
	  

	(and address if different than that listed on this Subscription Certificate)
	  

	
	  

			
	Telephone number (including area code)	 	  
	  	

  

  

	*	You can only participate in the Oversubscription Privilege if you have subscribed for your full entitlement of new shares pursuant to the basic subscription. 


Please complete all applicable information and return to: COMPUTERSHARE TRUST COMPANY, N.A. 

By First Class Mail: Computershare Trust Company, N.A., Corporate Actions Voluntary Offer, P.O. Box 43011,
Providence, RI 02940-3011 
 By Express Mail or Overnight Delivery: Computershare Trust Company, N.A., Corporate Actions Voluntary
Offer, 250 Royall Street, Suite V, Canton, MA 02021 
 DELIVERY OF THIS SUBSCRIPTION CERTIFICATE TO AN ADDRESS OTHER THAN AS SET FORTH
ABOVE DOES NOT CONSTITUTE A VALID DELIVERY. 
 Any questions regarding this Subscription Certificate and Subscription Rights Offering
may be directed to Georgeson LLC, the Information Agent, toll free at (866) 628-6024.