Exhibit 4.1


 




	
  

  	
  THIS CERTIFIES
  THAT is the owner of CUSIP DATED COUNTERSIGNED AND REGISTERED: COMPUTERSHARE
  TRUST COMPANY, N.A. TRANSFER AGENT AND REGISTRAR, FULLY-PAID AND
  NON-ASSESSABLE SHARES OF COMMON STOCK OF Sientra, Inc. (hereinafter called
  the “Company”), transferable on the books of the Company in person or by duly
  authorized attorney, upon surrender of this Certificate properly endorsed.
  This Certificate and the shares represented hereby, are issued and shall be
  held subject to all of the provisions of the Certificate of Incorporation, as
  amended, and the By-Laws, as amended, of the Company (copies of which are on
  file with the Company and with the Transfer Agent), to all of which each
  holder, by acceptance hereof, assents. This Certificate is not valid unless
  countersigned and registered by the Transfer Agent and Registrar. Witness the
  facsimile seal of the Company and the facsimile signatures of its duly
  authorized officers. COMMON STOCK PAR VALUE $0.01 COMMON STOCK THIS
  CERTIFICATE IS TRANSFERABLE IN CANTON, MA, JERSEY CITY, NJ AND COLLEGE
  STATION, TX SEE REVERSE FOR CERTAIN DEFINITIONS Certificate Number Shares .
  SIENTRA, INC. INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE FACSIMILE
  SIGNATURE TO COME FACSIMILE SIGNATURE TO COME President Secretary By
  AUTHORIZED SIGNATURE 2003 DELAWARE SIENTRA, INC.
  ZQ|CERT#|COY|CLS|RGSTRY|ACCT#|TRANSTYPE|RUN#|TRANS# 82621J 10 5 DD-MMM-YYYY *
  * 000000* * * * * * * * * * * * * * * * * * * * * 000000* * * * * * * * * * *
  * * * * * * * * * * 000000* * * * * * * * * * * * * * * * * * * * * 000000* *
  * * * * * * * * * * * * * * * * * * * 000000* * * * * * * * * * * * * * **
  Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr.
  Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander David
  Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample ****
  Mr. Alexander David Sample **** Mr. Alexander David Sample **** Mr. Alexander
  David Sample **** Mr. Alexander David Sample **** Mr. Alexander David Sample
  **** Mr. Sample **** Mr. Sample
  **000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares***
  *000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****
  000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****0
  00000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****00
  0000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000
  000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****0000
  00**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****00000
  0**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000
  **Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000*
  *Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**
  Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**Shares****000000**S
  ***ZERO HUNDRED THOUSAND ZERO HUNDRED AND ZERO*** MR. SAMPLE & MRS.
  SAMPLE & MR. SAMPLE & MRS. SAMPLE ZQ00000000 Certificate Numbers
  1234567890/1234567890 1234567890/1234567890 1234567890/1234567890
  1234567890/1234567890 1234567890/1234567890 1234567890/1234567890 Total
  Transaction Num/No. 123456 Denom. 123456 Total 1234567 MR A SAMPLE
  DESIGNATION (IF ANY) ADD 1 ADD 2 ADD 3 ADD 4 PO BOX 43004, Providence, RI
  02940-3004 CUSIP XXXXXX XX X Holder ID XXXXXXXXXX Insurance Value
  1,000,000.00 Number of Shares 123456 DTC 12345678 123456789012345 

  






 


 












	
  

  	
  The IRS
  requires that we report the cost basis of certain shares acquired after
  January 1, 2011. If your shares were covered by the legislation and you have
  sold or transferred the shares and requested a specific cost basis
  calculation method, we have processed as requested. If you did not specify a
  cost basis calculation method, we have defaulted to the first in, first out
  (FIFO) method. Please visit our website or consult your tax advisor if you
  need additional information about cost basis. If you do not keep in contact
  with us or do not have any activity in your account for the time periods
  specified by state law, your property could become subject to state unclaimed
  property laws and transferred to the appropriate state. For value received,
  hereby sell, assign and transfer unto Shares  Attorney Dated: 20 Signature: Signature:  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 whatever.
  PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER OF ASSIGNEE (PLEASE
  PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING POSTAL ZIP CODE, OF ASSIGNEE)
  of the common stock represented by the within Certificate, and do hereby
  irrevocably constitute and appoint to transfer the said stock on the books of
  the within-named Company with full power of substitution in the premises. .
  SIENTRA, INC. THE COMPANY WILL FURNISH WITHOUT CHARGE TO EACH SHAREHOLDER WHO
  SO REQUESTS, A SUMMARY OF THE POWERS, DESIGNATIONS, PREFERENCES AND RELATIVE,
  PARTICIPATING, OPTIONAL OR OTHER SPECIAL RIGHTS OF EACH CLASS OF STOCK OF THE
  COMPANY AND THE QUALIFICATIONS, LIMITATIONS OR RESTRICTIONS OF SUCH
  PREFERENCES AND RIGHTS, AND THE VARIATIONS IN RIGHTS, PREFERENCES AND
  LIMITATIONS DETERMINED FOR EACH SERIES, WHICH ARE FIXED BY THE CERTIFICATE OF
  INCORPORATION OF THE COMPANY, AS AMENDED, AND THE RESOLUTIONS OF THE BOARD OF
  DIRECTORS OF THE COMPANY, AND THE AUTHORITY OF THE BOARD OF DIRECTORS TO
  DETERMINE VARIATIONS FOR FUTURE SERIES. SUCH REQUEST MAY BE MADE TO THE
  OFFICE OF THE SECRETARY OF THE COMPANY OR TO THE TRANSFER AGENT. THE BOARD OF
  DIRECTORS MAY REQUIRE THE OWNER OF A LOST OR DESTROYED STOCK CERTIFICATE, OR
  HIS LEGAL REPRESENTATIVES, TO GIVE THE COMPANY A BOND TO INDEMNIFY IT AND ITS
  TRANSFER AGENTS AND REGISTRARS AGAINST ANY CLAIM THAT MAY BE MADE AGAINST
  THEM ON ACCOUNT OF THE ALLEGED LOSS OR DESTRUCTION OF ANY SUCH CERTIFICATE.
  Signature(s) Guaranteed: Medallion Guarantee Stamp 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. 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 (Cust) (Minor) TEN ENT - as tenants by the
  entireties under Uniform Gifts to Minors Act (State) JT TEN - as joint
  tenants with right of survivorship UNIF TRF MIN ACT - Custodian (until age )
  and not as tenants in common (Cust) under Uniform Transfers to Minors Act
  (Minor) (State) Additional abbreviations may also be used though not in the
  above list.