exv10w100



 





EXHIBIT 10-100



NEITHER THIS WARRANT NOR THE SHARES ISSUABLE UPON EXERCISE HEREOF HAVE BEEN REGISTERED UNDER THE
SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”) OR REGISTERED OR QUALIFIED UNDER ANY
STATE SECURITIES LAWS IN RELIANCE UPON AN EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE
SECURITIES ACT PURSUANT TO REGULATION D AND SUCH STATE SECURITIES LAWS. NEITHER THIS WARRANT NOR
THE SHARES ISSUABLE UPON EXERCISE HEREOF MAY BE SOLD, OR TRANSFERRED UNTIL (i) A REGISTRATION
STATEMENT UNDER THE SECURITIES ACT AND SUCH APPLICABLE STATE SECURITIES LAWS SHALL HAVE BECOME
EFFECTIVE WITH REGARD THERETO, OR (ii) IN THE OPINION OF COUNSEL, ACCEPTABLE TO THE COMPANY,
REGISTRATION OR QUALIFICATION UNDER THE SECURITIES ACT OR SUCH APPLICABLE STATE SECURITIES LAWS IS
NOT REQUIRED IN CONNECTION WITH SUCH PROPOSED OFFER, SALE OR TRANSFER.



THE SECURITIES EVIDENCED BY THIS CERTIFICATE ARE SUBJECT TO CERTAIN RESTRICTIONS AS SET FORTH IN A
COMMON STOCK AND WARRANT AGREEMENT BETWEEN THE COMPANY AND THE SHAREHOLDER DATED AS OF
                                        ,
20___ A COPY OF WHICH IS AVAILABLE UPON THE REQUEST OF THE REGISTERED HOLDER
HEREOF TO THE SECRETARY OF THE COMPANY.




STOCK PURCHASE WARRANT




Certificate No:                                         




To Purchase                                          Shares of Common Stock of




Sedona Corporation




     THIS CERTIFIES that, for value received,                                          hereinafter set forth, at any time on or
after the date hereof (the “Initial Exercise Date”) and on or prior to the close of business on
                                        , 20___
(the “Termination Date”) but not thereafter, to subscribe for and purchase from
Sedona Corporation, a corporation incorporated in the State of Pennsylvania (the “Company”), up to
                                                            
shares (the “Warrant Shares”) of Common Stock, $0.001 par value, of the
Company (the “Common Stock”) at a purchase price of (the “Exercise Price”) $  per share. The
Exercise Price and the number of shares for which the Warrant is exercisable shall be subject to
adjustment as provided herein.



          1. Title to Warrant. Prior to the Termination Date and subject to compliance with
applicable laws, this Warrant and all rights hereunder are transferable, in whole or in part, upon
the written consent of the Company and pursuant to the terms of the Purchase Agreement, by the
holder hereof in person or by duly authorized attorney, upon surrender of this Warrant to the
Company together with the Assignment Form annexed hereto properly endorsed.




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          2. Authorization of Shares. The Company covenants that all shares of Common Stock
which may be issued upon the exercise of this Warrant will, upon due and proper exercise of by this
Warrant, be duly authorized, validly issued, fully paid and nonassessable and free from all taxes,
liens and charges in respect of the issue thereof (other than any taxes in respect of any transfer
occurring contemporaneously with such issue).




          3. Exercise of Warrant.




          (a) Except as provided in Section 4 herein, exercise of the purchase rights represented by
this Warrant shall be made by the surrender of this Warrant and the Notice of Exercise Form annexed
hereto duly executed, at the office of the Company and upon payment of the Exercise Price of the
shares thereby purchased by wire transfer or cashier’s check drawn on a United States bank. The
holder of this Warrant shall be entitled to receive a certificate for the number of shares of
Common Stock so purchased. Certificates for shares purchased hereunder shall be delivered to the
holder hereof within five (5) Trading Days after the date on which this Warrant shall have been
exercised as aforesaid. This Warrant shall be deemed to have been exercised and such certificate or
certificates 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 by payment to the Company of the Exercise Price and
all taxes required to be paid by Holder, if any, pursuant to Section 5 prior to the issuance of
such shares, have been paid.




          (b) If this Warrant shall have been exercised in part, the Company shall, at the time of
delivery of the certificate or certificates representing Warrant Shares, deliver to Holder a new
Warrant evidencing the rights of Holder to purchase the unpurchased shares of Common Stock under
this Warrant, which new Warrant shall in all other respects be identical with this Warrant.




          (c) Each certificate representing Warrant Shares shall bear a legend substantially in the
following form:





THE SECURITIES EVIDENCED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE U.S.
SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR REGISTERED OR
QUALIFIED UNDER ANY STATE SECURITIES LAWS AND HAVE BEEN ISSUED IN RELIANCE UPON AN
EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND SUCH LAWS.
NEITHER THIS SECURITY NOR ANY INTEREST OR PARTICIPATION HEREIN MAY BE OFFERED, SOLD
OR TRANSFERRED UNTIL (i) A REGISTRATION STATEMENT UNDER THE SECURITIES ACT AND SUCH
APPLICABLE STATE SECURITIES LAWS SHALL HAVE BECOME EFFECTIVE WITH REGARD THERETO, OR
(ii) IN THE OPINION OF COUNSEL, ACCEPTABLE TO THE COMPANY, REGISTRATION OR
QUALIFICATION UNDER THE SECURITIES ACT OR SUCH APPLICABLE STATE SECURITIES LAWS IS
NOT REQUIRED IN CONNECTION WITH SUCH PROPOSED OFFER, SALE OR TRANSFER.



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THE SECURITIES EVIDENCED BY THIS CERTIFICATE ARE SUBJECT TO CERTAIN RESTRICTIONS AS
SET FORTH IN A COMMON STOCK AND WARRANT AGREEMENT BETWEEN THE COMPANY AND THE
SHAREHOLDER DATED AS OF                                         , 20___
A COPY OF WHICH IS AVAILABLE UPON THE
REQUEST OF THE REGISTERED HOLDER HEREOF TO THE SECRETARY OF THE COMPANY.



          The foregoing legend shall be removed from the certificates representing the Warrant Shares,
at the request of the Holder, at such time as they become eligible for resale pursuant to Rule
144(k) under the Securities Act or at such time as the Holder shall have obtained an opinion of
counsel, reasonably acceptable to the Company, to the effect that the Warrant Shares proposed to be
disposed of may lawfully be so disposed of without registration, qualification or legend.




          4. Restrictions. The Warrant Shares may not be transferred until the earlier of the
following (i) registration of the Shares is completed or (ii)                                         , 20_.




          No Fractional Shares or Scrip. No fractional shares or scrip representing fractional
shares shall be issued upon the exercise of this Warrant. As to any fraction of a share which
Holder would otherwise be entitled to purchase upon such exercise, the Company shall pay a cash
adjustment in respect of such final fraction in an amount equal to the Exercise Price.




          5. Charges, Taxes, etc. Issuance of certificates for shares of Common Stock upon the
exercise of this Warrant shall be made without charge to the holder hereof for any issue other
incidental expense in respect of the issuance of such certificate, which shall be paid by the
Company, and such certificates shall be issued in the name of the holder of this Warrant or in such
name or names as may be directed by the holder of this Warrant; provided, however, that in the
event certificates for shares of Common Stock are to be issued in a name other than the name of the
holder of this Warrant, this Warrant when surrendered for exercise shall be accompanied by the
Assignment Form attached hereto duly executed by the holder hereof; and the Company may require, as
a condition thereto, the payment of a sum sufficient to reimburse it for any transfer tax
incidental thereto.




          6. Transfer, Division and Combination.




          (a) Subject to compliance with any applicable securities laws, transfer of this Warrant and
all rights hereunder, in whole or in part, shall be registered on the books of the Company to be
maintained for such purpose, upon surrender of this Warrant at the principal office of the Company,
together with a written assignment of this Warrant substantially in the form attached hereto duly
executed by 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 and in
the denomination or denominations specified in such instrument of assignment, and shall issue to
the assignor a new Warrant evidencing the




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portion of this Warrant not so assigned, and this Warrant shall promptly be cancelled. A
Warrant, if properly assigned, may be exercised by a new holder for the purchase of shares of
Common Stock without having a new Warrant issued.




          (b) 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 Holder or its agent or attorney.
Subject to compliance with Section 6(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.




          (c) The Company shall prepare, issue and deliver at its own expense (other than transfer
taxes) the new Warrant or Warrants under this Section 6.




          (d) The Company agrees to maintain, at its aforesaid office, books for the registration and
the registration of transfer of the Warrants.




          7. No Rights as Shareholder until Exercise. This Warrant does not entitle the holder
hereof to any voting rights or other rights as a shareholder of the Company prior to the exercise
hereof.




          8. 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 certificate 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 may 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.




          9. 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 be a Saturday, Sunday or
a legal holiday, then such action may be taken or such right may be exercised on the next
succeeding day not a Saturday, Sunday or legal holiday.




          10. Adjustments of Exercise Price and Number of Warrant Shares.




          (a) Stock Splits, etc. The number and kind of securities purchasable upon the
exercise of this Warrant and the Exercise Price shall be subject to adjustment from time to time
upon the happening of any of the following. In case the Company shall (i) pay a dividend in shares
of Common Stock or make a distribution in shares of Common Stock to holders of its outstanding
Common Stock, (ii) subdivide its outstanding shares of Common Stock into a greater number of shares
of Common Stock, (iii) combine its outstanding shares of Common Stock into a smaller number of
shares of Common Stock or (iv) issue any shares of its capital stock in a reclassification of the
Common Stock, then the number of Warrant Shares purchasable upon exercise of this Warrant
immediately prior thereto shall be adjusted so that the holder of this



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Warrant shall be entitled to receive the kind and number of Warrant Shares or other securities
of the Company which he would have owned or have been entitled to receive had such Warrant been
exercised in advance thereof. Upon each such adjustment of the kind and number of Warrant Shares
or other securities of the Company which are purchasable hereunder, the holder of this Warrant
shall thereafter be entitled to purchase the number of Warrant Shares or other securities resulting
from such adjustment at an Exercise Price per Warrant Share or other security obtained by
multiplying the Exercise Price in effect immediately prior to such adjustment by the number of
Warrant Shares purchasable pursuant hereto immediately prior to such adjustment and dividing by the
number of Warrant Shares or other securities of the Company resulting from such adjustment. An
adjustment made pursuant to this paragraph shall become effective immediately after the effective
date of such event retroactive to the record date, if any, for such event.




          (b) Reorganization, Reclassification, Merger, Consolidation or Disposition of Assets.
In case the Company shall reorganize its capital, reclassify its capital stock, consolidate or
merge with or into another corporation (where the Company is not the surviving corporation or where
there is a change in or distribution with respect to the Common Stock of the Company), or sell,
transfer or otherwise dispose of all or substantially all its property, assets or business to
another corporation and, pursuant to the terms of such reorganization, reclassification, merger,
consolidation or disposition of assets, shares of common stock of the successor or acquiring
corporation, or any cash, shares of stock or other securities or property of any nature whatsoever
(including warrants or other subscription or purchase rights) in addition to or in lieu of common
stock of the successor or acquiring corporation (“Other Property”), are to be received by or
distributed to the holders of Common Stock of the Company, then Holder shall have the right
thereafter to receive, upon exercise of this Warrant, the number of shares of common stock of the
successor or acquiring corporation or of the Company, if it is the surviving corporation, and Other
Property receivable upon or as a result of such reorganization, reclassification, merger,
consolidation or disposition of assets by a holder of the number of shares of Common Stock for
which this Warrant is exercisable immediately prior to such event. In case of any such
reorganization, reclassification, merger, consolidation or disposition of assets, the successor or
acquiring corporation (if other than the Company) shall expressly assume the due and punctual
observance and performance of each and every covenant and condition of this Warrant to be performed
and observed by the Company and all the obligations and liabilities hereunder, subject to such
modifications as may be deemed appropriate (as determined in good faith by resolution of the Board
of Directors of the Company) in order to provide for adjustments of shares of Common Stock for
which this Warrant is exercisable which shall be as nearly equivalent as practicable to the
adjustments provided for in this Section 10. For purposes of this Section 10, “common stock of the
successor or acquiring corporation” shall include stock of such corporation of any class which is
not preferred as to dividends or assets over any other class of stock of such corporation and which
is not subject to redemption and shall also include any evidences of indebtedness, shares of stock
or other securities which are convertible into or exchangeable for any such stock, either
immediately or upon the arrival of a specified date or the happening of a specified event and any
warrants or other rights to subscribe for or purchase any such stock. The foregoing provisions of
this Section 10 shall similarly apply to successive reorganizations, reclassifications, mergers,
consolidations or disposition of assets.




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          11. Voluntary Adjustment by the Company. The Company may, at its sole discretion, at
any time during the term of this Warrant, reduce the then current Exercise Price to any amount and
for any period of time deemed appropriate by the Board of Directors of the Company. The Company
may also, at its sole discretion, extend the term of the Warrant for any period of time.




          12. Notice of Adjustment. Whenever the number of Warrant Shares or number or kind of
securities or other property purchasable upon the exercise of this Warrant or the Exercise Price is
adjusted, as herein provided, the Company shall promptly mail by registered or certified mail,
return receipt requested, to the holder of this Warrant notice of such adjustment or adjustments
setting forth the number of Warrant Shares (and other securities or property) purchasable upon the
exercise of this Warrant and the Exercise Price of such Warrant Shares (and other securities or
property) after such adjustment, setting forth a brief statement of the facts requiring such
adjustment and setting forth the computation by which such adjustment was made. Such notice, in
the absence of manifest error, shall be conclusive evidence of the correctness of such adjustment.




          13. Notice of Corporate Action. If at any time:




          (a) the Company shall take a record of the holders of its Common Stock for the purpose of
entitling them to receive a dividend or other distribution, or any right to subscribe for or
purchase any evidences of its indebtedness, any shares of stock of any class or any other
securities or property, or to receive any other right, or




          (b) there shall be any capital reorganization of the Company, any reclassification or
recapitalization of the capital stock of the Company or any consolidation or merger of the Company
with, or any sale, transfer or other disposition of all or substantially all the property, assets
or business of the Company to, another corporation or,




          (c) there shall be a voluntary or involuntary dissolution, liquidation or winding up of the
Company;



then, in any one or more of such cases, the Company shall give to Holder (i) at least 10 days’
prior written notice of the date on which a record date shall be selected for such dividend,
distribution or right or for determining rights to vote in respect of any such reorganization,
reclassification, merger, consolidation, sale, transfer, disposition, liquidation or winding up,
and (ii) in the case of any such reorganization, reclassification, merger, consolidation, sale,
transfer, disposition, dissolution, liquidation or winding up, at least 10 days’ prior written
notice of the date when the same shall take place. Such notice in accordance with the foregoing
clause also shall specify (i) the date on which any such record is to be taken for the purpose of
such dividend, distribution or right, the date on which the holders of Common Stock shall be
entitled to any such dividend, distribution or right, and the amount and character thereof, and
(ii) the date on which any such reorganization, reclassification, merger, consolidation, sale,
transfer, disposition, dissolution, liquidation or winding up is to take place and the time, if any
such time is to be fixed, as of which the holders of Common Stock shall be entitled to exchange
their shares of Common Stock for securities or other property deliverable upon such disposition,


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dissolution, liquidation or winding up. Each such written notice shall be sufficiently given if
addressed to Holder at the last address of Holder appearing on the books of the Company and
delivered in accordance with Section 15(d).




          14. Authorized Shares. The Company covenants that during the period the Warrant is
outstanding, it will reserve from its authorized and unissued Common Stock a sufficient number of
shares to provide for the issuance of the Warrant Shares upon the exercise of any purchase rights
under this Warrant. The Company further covenants that its issuance of this Warrant shall
constitute full authority to its officers who are charged with the duty of executing stock
certificates to execute and issue the necessary certificates for the Warrant Shares upon the
exercise of the purchase rights under this Warrant. The Company will take all such reasonable
action as may be necessary to assure that such Warrant Shares may be issued as provided herein
without violation of any applicable law or regulation, or of any requirements of the Principal
Market upon which the Common Stock may be listed.




          The Company will (a) not increase the par value of any shares of Common Stock receivable upon
the exercise of this Warrant above the amount payable therefor upon such exercise immediately prior
to such increase in par value, (b) take all such action as may be necessary or appropriate in order
that the Company may validly and legally issue fully paid and nonassessable shares of Common Stock
upon the exercise of this Warrant, and (c) use its best efforts to obtain all such authorizations,
exemptions or consents from any public regulatory body having jurisdiction thereof as may be
necessary to enable the Company to perform its obligations under this Warrant.




          Before taking any action which would result in an adjustment in the number of shares of Common
Stock for which this Warrant is exercisable or in the Exercise Price, the Company shall obtain all
such authorizations or exemptions thereof, or consents thereto, as may be necessary from any public
regulatory body or bodies having jurisdiction thereof.




          15. Miscellaneous.




          (a) Jurisdiction. This Warrant shall constitute a contract under the laws of the
Commonwealth of Pennsylvania, without regard to its conflict of law, principles or rules. Each of
the parties hereto hereby irrevocably and unconditionally consents to submit to the non-exclusive
jurisdiction of the courts of the Commonwealth of Pennsylvania and of the United States of America,
located in the Commonwealth of Pennsylvania, for any action, proceeding or investigation in any
court or before any governmental authority (“Litigation”) arising out of or relating to this
Warrant and the transactions contemplated hereby, and further agrees that service of any process,
summons, notice or document by U.S. registered mail to its respective address set forth in this
Warrant shall be effective service of process for any Litigation brought against it in any such
court. Each of the parties hereto hereby irrevocably and unconditionally waives any objection to
the laying of venue of any Litigation arising out of this Warrant in the courts of the Commonwealth
of Pennsylvania or the United States of America, located in the Commonwealth of Pennsylvania, and
hereby further irrevocably and unconditionally waives and agrees not to plead or claim in any such
court that any such Litigation brought in any such court has been brought in an inconvenient forum.




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          (b) Restrictions. The holder hereof 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.




          (c) 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 Holder’s rights, powers or remedies, notwithstanding all rights hereunder terminate on
the Termination Date.




          (d) Notices. Any notice, request or other document required or permitted to be given
or delivered to the holder hereof by the Company shall be delivered to the address set forth in
that certain Common Stock and Warrants Purchase Agreement dated ___, 20___, or at such other
address or addresses as may have been furnished in writing by any holder to the Company.




          All notices and other communications from Holder to the Company shall be delivered to:




	 	 	 
	 

	 	SEDONA Corporation

1003 W. Ninth Avenue

Second Floor

King of Prussia, PA 19406

Attention: Chief Financial Officer

PHONE: (610) 337-8400

FAX: (610) 337-8490
	 
	 	 
	 

	 	With a copy to:
	 
	 	 
	 

	 	White and Williams, LLP

One Penn Plaza

Suite 1801

New York, New York 10119

Attention: Carl Seldin Koerner, Esq.

PHONE: 212-244-9500

FAX: 212-244-6200





or at such other address or addresses as may have been furnished in writing by the Company to
Holder.




          (e) No Rights as Shareholder. Until the exercise of this Warrant, the Holder shall
not have or exercise any rights by virtue hereof as a shareholder of the Company.




          (f) Successors and Assigns. Neither this Warrant nor any rights of the Holder or the
Company hereunder may be assigned by the Holder except as set forth in the Purchase Agreement and
upon the written consent of the Company. This Warrant and the rights and obligations evidenced
hereby shall inure to the benefit of and be binding upon the successors of the Company and the
Holder.




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          (g) Amendment. This Warrant may be modified by the Company from time to time to cure
any ambiguity or correct or supplement any provision contained herein which may be defective or
inconsistent with any other provision herein, or to make any other provisions in regard to matters
or questions arising hereunder which the Company may deem necessary or desirable and which shall
not materially adversely affect the interest of the Holder and, in addition, the Company may
modify, supplement, or alter this Warrant at any time with the written consent of the Holder.




          (h) 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.




          (i) 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.




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          IN WITNESS WHEREOF, the Company has caused this Warrant to be executed by its officer
thereunto duly authorized.




Dated:                                         




	 	 	 	 	 
	 	SEDONA Corporation

 	 
	 	By:  	 	 
	 	 	Anita M. Primo 	 
	 	 	Vice President and Chief Financial Officer 	 
	 




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NOTICE OF EXERCISE




	 	 	 
	To:

	 	SEDONA Corporation






     (1) The undersigned hereby elects to purchase                                                     shares of Common Stock (the “Common
Stock”), of Sedona Corporation pursuant to the terms of the attached Warrant, and tenders herewith
payment of the exercise price in full, together with all applicable transfer taxes, if any.



     (2) Please issue a certificate or certificates representing said shares of Common Stock in the
name of the undersigned or in such other name as is specified below:



                                                                       
         



(Name)




                                                                       
         



(Address)




                                                                       
         




Dated:                                         




	 	 	 	 	 
	 
	 	 	 	 
	 

	 	Name of entity:	 	 
	 

	 	 	 	 
	 

	 	(if applicable)	 	 
	 
	 	 	 	 
	 

	 	Signed:	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 

	 	Name:	 	 
	 

	 	 	 	 
	 

	 	 	 	[Print]
	 
	 	 	 	 
	 

	 	Title:	 	 
	 

	 	 	 	 
	 

	 	(if applicable)	 	 
	 
	 	 	 	 
	 

	 	Address:	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	Tax Identification Number	 	 
	 

	 	 	 	 





 









 





SEDONA CORPORATION




WARRANT ASSIGNMENT FORM




(To assign the foregoing warrant, execute

this form and supply required information.

Do not use this form to exercise the warrant.)




     FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are hereby assigned
to
                    
                    
                    
                    
                    
                    
                     whose address is
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    .



Dated:
                                        ,                    
                    




	 	 	 	 	 
	 
	 	 	 	 
	 

	 	Name of entity:	 	 
	 

	 	 	 	 
	 

	 	(if applicable)	 	 
	 
	 	 	 	 
	 

	 	Signed:	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 

	 	Name:	 	 
	 

	 	 	 	 
	 

	 	 	 	[Print]
	 
	 	 	 	 
	 

	 	Title:	 	 
	 

	 	 	 	 
	 

	 	(if applicable)	 	 
	 
	 	 	 	 
	 
	 	Address:	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	 





Signature Guaranteed:     
                    
                    
                    
                    
                    



NOTE: The signature to this Assignment Form must correspond with the name as it appears on the
face of the Warrant, without alteration or enlargement or any change whatsoever, and must be
guaranteed by a bank or trust company. Officers of corporations and those acting in an fiduciary
or other representative capacity should file proper evidence of authority to assign the foregoing
Warrant.