hsto-ex41_170.htm



 

Exhibit 4.1



DELAWARE _ SEAL HISTOGEN INC. CORPORATE July 13, 2005 HG FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK, $0.0001 PAR VALUE PER SHARE, OF Histogen Inc. transferable on the books of the Corporation in person or by duly authorized attorney upon surrender of this Certificate properly endorsed. This Certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar. WITNESS the facsimile seal of the Corporation and the facsimile signatures of its duly authorized officers. Dated: This certifies that is the record holder of INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE COUNTERSIGNED AND REGISTERED: AMERICAN STOCK TRANSFER & TRUST COMPANY, LLC (BROOKLYN, NY) TRANSFER AGENT AND REGISTRAR BY: AUTHORIZED SIGNATURE PRESIDENT & CHIEF EXECUTIVE OFFICER EXECUTIVE VICE PRESIDENT & CHIEF FINANCIAL OFFICER CUSIP 43358Y 10 3 SEE REVERSE FOR CERTAIN DEFINITIONS AND LEGENDS  

 



 

The Corporation shall furnish without charge to each stockholder who so requests a statement of the powers, designations, preferences and relative, participating, optional or other special rights of each class of stock of the Corporation or series thereof and the qualifications, limitations or restrictions of such preferences and/or rights. Such requests shall be made to the Corporation’s Secretary at the principal office of the Corporation.

KEEP THIS CERTIFICATE IN A SAFE PLACE. IF IT IS LOST, STOLEN, OR DESTROYED THE CORPORATION WILL REQUIRE A BOND INDEMNITY AS A CONDITION TO THE ISSUANCE OF A REPLACEMENT CERTIFICATE.

The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations:

 


	
TEN COM
	
–
	
as tenants in common
	
UNIF GIFT MIN ACT
	
–
	
 
	
Custodian
	
 
	
	
TEN ENT
	
–
	
as tenants by the entireties
	
 
	
 
	
(Cust)
	
 
	
(Minor)
	
	
JT TEN
	
–
	
as joint tenants with right of
	
 
	
 
	
under Uniform Gifts to Minors
	
	
 
	
 
	
survivorship and not as tenants
	
 
	
 
	
Act
	
 
	
	
 
	
 
	
in common
	
 
	
 
	
(State)
	
	
COM PROP
	
–
	
as community property
	
UNIF TRF MIN ACT
	
–
	
 
	
Custodian (until age 
	
 
	
)

	
 
	
 
	
 
	
 
	
 
	
(Cust)
	
 
	
 
	
 

	
 
	
 
	
 
	
 
	
 
	
 
	
	
 
	
 
	
 
	
 
	
 
	
 
	
under Uniform Transfers
	
	
 
	
 
	
 
	
 
	
 
	
(Minor)
	
 
	
	
 
	
 
	
 
	
 
	
 
	
to Minors Act
	
 
	
	
 
	
 
	
 
	
 
	
 
	
 
	
(State)
	
	
 
	
 
	
 
	
 
	
 
	
 
	
	
 
	
 
	
 
	
 
	
 
	
 
	



 

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

FOR VALUE RECEIVED, _____________________________________________________ hereby sell(s), assign(s) and transfer(s) unto


	
PLEASE INSERT SOCIAL SECURITY OR OTHER
IDENTIFYING NUMBER OF ASSIGNEE

	
 




 

 

 

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

 

 

 


	
 
	
shares

	
of the capital stock represented by within Certificate, and do hereby irrevocably constitute and appoint 

	
 
	
attorney-in-fact

	
to transfer the said stock on the books of the within named Corporation with full power of the substitution in the premises. 




 


	
Dated
	
 
	
 

	
 
	
 
	
 




 

 



 

 


						
	
 
	
X
	
 

	
 
	
 
	
 

	
 
	
X
	
 

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

	
 
	
 
	
 

	
 
	
 
	
 

	
By
	
 
	
 
	
 
	
 

	
THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION, (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15. GUARANTEES BY A NOTARY PUBLIC ARE NOT ACCEPTABLE. SIGNATURE GUARANTEES MUST NOT BE DATED.