Exhibit 10.32



 


Exhibit 10.32


 


This
warrant and the securities issuable upon the exercise hereof have not been registered under the Securities Act of 1933, as amended.
They may not be sold, offered for sale, pledged, hypothecated, or otherwise transferred except pursuant to an effective registration
statement under the Securities Act of 1933, as amended, or an opinion of counsel satisfactory to the Company the registration is
not required.


 


	No. of Shares: 	______	Issue Date:	February ___, 2013
	Exercise Price:	$2.50	Expiration Date:	February ___, 2015


 


INFINITY
ENERGY RESOURCES, INC.


 


Common
Stock Purchase Warrant


 


INFINITY ENERGY RESOURCES,
INC. (the “Company”), a Delaware corporation, hereby certifies
that, for value received of $0.001 per Warrant, ___________________________ (the “Holder”), whose address
is _________________________, is entitled, subject to the terms set forth below, at any time, or from time to time, after
the date hereof and before the Expiration Date (as defined below), to purchase from the Company __________________ (_________)
shares (the “Shares”) of common stock, $0.0001 par value (the “Common Stock”), of the Company
at a price of Two Dollars and Fifty Cents ($2.50) per Share. The purchase price per Share, as adjusted from time to time
pursuant to the provisions of this Warrant, is referred to as the “Exercise Price.” The Company is issuing this
Warrant in connection with an 8% Note (the “Note”) issued to the Holder by the Company.


 


		1.	Term of the Warrant.



 


1.1               
Time of Exercise. Subject to the provisions of Sections 1.5, “Transfer
and Assignment,” and 3.1, “Registration and Legends,” this Warrant may be exercised at any time and from time to
time after 9:00 a.m., local time, on February ___, 2013 (the “Exercise Commencement Date”), but no later
than 5:00 p.m., local time, February ___, 2015 (the “Expiration Date”), at which point it shall become
void and all rights under this Warrant shall cease.


 


1.2               
Manner of Exercise. Subject to the provisions of Section 1.4, “Holder
as Owner,” the Holder may exercise this Warrant in whole or in part on the date hereof or by presentation and surrender thereof
to the Company at its principal executive office or at the office of its stock transfer agent, if any, the subscription form annexed
hereto (the “Subscription Form”) duly executed and accompanied by payment as follows: 


 



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1.2.1          
in cash or by certified or official bank check, payable to the order of the Company, in the
amount equal to the Exercise Price multiplied by the number of Shares specified in such form, together with all taxes applicable
upon such exercise; 


 


1.2.2          
by surrendering to the Company that number of Shares owned by the Holder whose value is equal
to the Exercise Price multiplied by the number of Shares specified in the Subscription Form; 


 


1.2.3          
by surrendering the right to acquire a number of Shares having an aggregate value such that
the amount by which the aggregate value of such Shares exceeds the aggregate Exercise Price is equal to the Exercise Price; 


 


1.2.4          
any combination of the foregoing; or 


 


1.2.5          
any other manner acceptable to the Company. 


 


For purposes of surrendering
Shares to satisfy the Exercise Price, the value of the Shares shall be equal to the current market price for Common Stock (the
“Market Price”) on the relevant date of such exercise of this Warrant from time to time (the “Exercise
Date”).


 


	X =	Y (A - B)
	A


 


Where


 


X -- The number
of Shares to be issued to the Holder.


 


Y -- The number
of Shares purchasable under this Warrant.


 


A -- The Market
Price of one Share.


 


B -- The Exercise
Price (as adjusted to the date of such calculations).


 


For purposes of this Section 1,
the Market Price of a Share shall mean the average of the closing bid and asked prices of Shares quoted on the Nasdaq Capital Market
or in the over-the-counter market in which the Shares are traded or the closing sale price quoted on any exchange on which the
Shares are listed, whichever is applicable, for the ten (10) trading days prior to the date of determination of Market Price (or
such shorter period of time during which such stock was traded over-the-counter or on such exchange). If the Shares are not traded
on the over-the-counter market or on an exchange, the Market Price shall be the price per Share at which the Company sold Common
Stock previous to the date of exercise.


 


1.2.6          
Upon receipt of this Warrant, with the Subscription Form duly executed and accompanied by
payment of the aggregate Exercise Price for the Shares for which this Warrant is then being exercised, the Company shall cause
to be issued certificates or other evidence of ownership for the total number of whole Shares for which this Warrant is being exercised
in such denominations as are required for delivery to the Holder, and the Company shall thereupon deliver such documents to the
Holder or its nominee.


 



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1.2.7          
If the Holder exercises this Warrant with respect to fewer than all of the Shares that may
be purchased under this Warrant, the Company shall execute a new Warrant for the balance of the Shares that may be purchased upon
exercise of this Warrant and deliver such new Warrant to the Holder.


 


1.2.8          
The Company covenants and agrees that it will pay when due and payable any and all transfer
taxes which may be payable in respect of the issue of this Warrant, or the issue of any Shares upon the exercise of this Warrant.
The Company shall not, however, be required to pay any transfer or other tax which may be payable in respect of any transfer involved
in the issuance or delivery of this Warrant or of the Shares in a name other than that of the Holder at the time of surrender,
and until the payment of such tax, the Company shall not be required to issue such Shares.


 


1.2.9          
The Company shall, at the time of any exercise of all or part of this Warrant, upon the request
of the Holder hereof, acknowledge in writing its continuing obligation to afford to such Holder any rights to which such Holders
shall continue to be entitled after such exercise in accordance with the provisions of this Warrant, provided that if the Holder
of this Warrant shall fail to make any such request, such failure shall not affect the continuing obligations of the Company to
afford to such Holder any such rights.


 


1.3               
Exchange of Warrant. This Warrant may be split-up, combined or exchanged
for another Warrant or Warrants of like tenor to purchase a like aggregate number of Shares. If the Holder desires to split-up,
combine or exchange this Warrant, he shall make such request in writing delivered to the Company at its corporate office and shall
surrender this Warrant and any other Warrants to be so split-up, combined or exchanged, the Company shall execute and deliver to
the person entitled thereto a Warrant or Warrants, as the case may be, as so requested. The Company shall not be required to effect
any split-up, combination or exchange that will result in the issuance of a Warrant entitling the Holder to purchase upon exercise
a fraction of a Share. The Company may require the Holder to pay a sum sufficient to cover any tax or governmental charge that
may be imposed in connection with any split-up, combination or exchange of Warrants. The term “Warrant” as used herein
includes any Warrants issued in substitution for or replacement of this Warrant, or into which this Warrant may be divided or exchanged.


 


1.4               
Holder as Owner. Prior to due presentment for registration of transfer
of this Warrant, the Company may deem and treat the Holder as the absolute owner of this Warrant (notwithstanding any notation
of ownership or other writing hereon) for the purpose of any exercise hereof and for all other purposes, and the Company shall
not be affected by any notice to the contrary. Irrespective of the date of issue and delivery of certificates for any Shares issuable
upon the exercise of the Warrant, each person in whose name any such certificate is issued shall be deemed to have become the holder
of record of the Shares represented thereby on the date on which all or a portion of the Warrant surrendered in connection with
the subscription therefor was surrendered and payment of the Exercise Price was tendered. No surrender of all or a portion of the
Warrant on any date when the stock transfer books of the Company are closed, however, shall be effective to constitute the person
or persons entitled to receive Shares upon such surrender as the record holder of such Shares on such date, but such person or
persons shall be constituted the record holder or holders of such Shares at the close of business on the next succeeding date on
which the stock transfer books are opened. Each person holding any Shares received upon exercise of Warrant shall be entitled to
receive only dividends or distributions payable to holders of record on or after the date on which such person shall be deemed
to have become the holder of record of such Shares.


 



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1.5               
Transfer and Assignment. This Warrant may not be sold, hypothecated,
exercised, assigned or transferred except in accordance with and subject to the provisions of the Securities Act of 1933, as amended
(“Act”) and any applicable state securities laws and regulations.


 


1.6               
Method for Assignment. Any assignment permitted under this Warrant shall
be made by surrender of this Warrant to the Company at its principal office with the form of assignment attached hereto duly executed
and funds sufficient to pay any transfer tax. In such event, the Company shall, without charge, execute and deliver a new Warrant
in the name of the assignee designated in such instrument of assignment and this Warrant shall promptly be canceled. This Warrant
may be divided or combined with other Warrants that carry the same rights upon presentation thereof at the corporate office of
the Company together with a written notice signed by the Holder, specifying the names and denominations in which such new Warrants
are to be issued.


 


1.7               
Rights of Holder. Nothing contained in this Warrant shall be construed
as conferring upon the Holder the right to vote or consent or receive notice as a stockholder in respect of any meetings of stockholders
for the election of directors or any other matter, or as having any rights whatsoever as a stockholder of the Company. If, however,
at any time prior to the expiration of this Warrant and prior to its exercise, any of the following shall occur:


 


1.7.1          
The Company shall take a record of the holders of its shares of Common Stock for the purpose
of entitling them to receive a dividend or distribution payable otherwise than in cash, or a cash dividend or distribution payable
otherwise than out of current or retained earnings, as indicated by the accounting treatment of such dividend or distribution on
the books of the Company; or


 


1.7.2          
The Company shall offer to the holders of its Common Stock any additional shares of capital
stock of the Company or securities convertible into or exchangeable for shares of capital stock of the Company, or any option,
right or warrant to subscribe therefor; or


 


1.7.3          
There shall be proposed any capital reorganization or reclassification of the Common Stock,
or a sale of all or substantially all of the assets of the Company, or a consolidation or merger of the Company with another entity;
or


 


1.7.4          
There shall be proposed a voluntary or involuntary dissolution, liquidation or winding up
of the Company; 


 


then, in any one or more
of said cases, the Company shall cause to be mailed to the Holder, at the earliest practicable time (and, in any event, not less
than thirty (30) days before any record date or other date set for definitive action), written notice of the date on which the
books of the Company shall close or a record shall be taken to determine the stockholders entitled to such dividend, distribution,
convertible or exchangeable securities or subscription rights, or entitled to vote on such reorganization, reclassification, sale,
consolidation, merger, dissolution, liquidation or winding up, as the case may be. Such notice shall also set forth such facts
as shall indicate the effect of such action (to the extent such effect may be known at the date of such notice) on the Exercise
Price and the kind and amount of the Common Stock and other securities and property deliverable upon exercise of this Warrant.
Such notice shall also specify the date as of which the holders of the Common Stock of record shall participate in said distribution
or subscription rights or shall be entitled to exchange their Common Stock for securities or other property deliverable upon such
reorganization, reclassification, sale, consolidation, merger, dissolution, liquidation or winding up, as the case may be (on which
date, in the event of voluntary or involuntary dissolution, liquidation or winding up of the Company, the right to exercise this
Warrant shall terminate). Without limiting the obligation of the Company to provide notice to the holder of actions hereunder,
the failure of the Company to give notice shall not invalidate such action of the Company.


 






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1.8               
Lost Warrant Certificate(s). Upon receipt by the Company of evidence
satisfactory to it of the loss, theft, destruction or mutilation of this Warrant, and, in the case of loss, theft or destruction
of reasonably satisfactory indemnification, including a surety bond if required by the Company, and upon surrender and cancellation
of this Warrant, if mutilated, the Company will cause to be executed and delivered a new Warrant of like tenor and date. Any such
new Warrant executed and delivered shall constitute an additional contractual obligation on the part of the Company, whether or
not this Warrant so lost, stolen, destroyed, or mutilated shall be at any time enforceable by anyone.


 


1.9               
Covenants of the Company. The Company covenants and agrees as follows:


 


1.9.1          
At all times it shall reserve and keep available for the exercise of this Warrant into Common
Stock such number of authorized shares of Common Stock as are sufficient to permit the exercise in full of this Warrant into Common
Stock; and


 


1.9.2          
All Shares issued upon exercise of the Warrant shall be duly authorized, validly issued and
outstanding, fully-paid and non-assessable.


 


		2.	Adjustment of the Exercise Price and Number of Shares Purchasable
Upon Exercise 



 


2.1               
Default in Payment of the Note. If the Company fails to pay the Note when due
whether on the Maturity Date, as such term is defined in the Note, or earlier acceleration thereof, without any action on the part
of the Company or the Holder, the Exercise Price shall automatically be reduced to Ten Cents ($0.10) per Share and the number
of Shares that the Holder may purchase from the Company under this Warrant shall automatically increase to _____________________________
(________) Shares.


 



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2.2               
Recapitalization. The number of Shares purchasable on exercise of this
Warrant and the Exercise Price therefor shall be subject to adjustment from time to time in the event that the Company shall: (i) pay
a dividend in, or make a distribution of, shares of Common Stock, (ii) subdivide its outstanding shares of Common Stock into
a greater number of shares, (iii) combine its outstanding shares of Common Stock into a smaller number of shares, or (iv) spin-off
a subsidiary by distributing, as a dividend or otherwise, shares of the subsidiary to its stockholders. In any such case, the total
number of shares purchasable on exercise of this Warrant immediately prior thereto shall be adjusted so that the Holder shall be
entitled to receive, at the same aggregate purchase price, the number of shares of Common Stock that the Holder would have owned
or would have been entitled to receive immediately following the occurrence of any of the events described above had this Warrant
been exercised in full immediately prior to the occurrence (or applicable record date) of such event. An adjustment made pursuant
to this Section 2 shall, in the case of a stock dividend or distribution, be made as of the record date and, in the case of a subdivision
or combination, be made as of the effective date thereof. If, as a result of any adjustment pursuant to this Section 2, the Holder
shall become entitled to receive shares of two or more classes of series of securities of the Company, the Board of Directors of
the Company shall equitably determine the allocation of the adjusted purchase price between or among shares or other units of such
classes or series and shall notify the Holder of such allocation.


 


2.3               
Merger or Consolidation. In the event of any reorganization or recapitalization
of the Company or in the event the Company consolidates with or merges into another entity or transfers all or substantially all
of its assets to another entity, then and in each such event, the Holder, on exercise of this Warrant as provided herein, at any
time after the consummation of such reorganization, recapitalization, consolidation, merger or transfer, shall be entitled, and
the documents executed to effectuate such event shall so provide, to receive the stock or other securities or property to which
the Holder would have been entitled upon such consummation if the Holder had exercised this Warrant immediately prior thereto.
In such case, the terms of this Warrant shall survive the consummation of any such reorganization, recapitalization, consolidation,
merger or transfer and shall be applicable to the shares of stock or other securities or property receivable on the exercise of
this Warrant after such consummation and as an exchange for a larger or smaller number of shares, as the case may be.


 


2.4               
Notice of Dissolution or Liquidation. Except as otherwise provided in
Section 2.2, “Merger or Consolidation,” in the case of any sale or conveyance of all or substantially all of the assets
of the Company in connection with a plan of complete liquidation of the Company, or in the case of the dissolution, liquidation
or winding-up of the Company, all rights under this Warrant shall terminate on a date fixed by the Company, such date so fixed
to be not earlier than the date of the commencement of the proceedings for such dissolution, liquidation or winding-up and not
later than thirty (30) days after such commencement date. Notice of such termination of purchase rights shall be given to the Holder
at least thirty (30) days prior to such termination date.


 


2.5               
Statement of Adjustment. Any adjustment pursuant to the provisions of
this Section 2 shall be made on the basis of the number of Shares which the Holder would have been entitled to acquire by exercise
of this Warrant immediately prior to the event giving rise to such adjustment and, as to the Exercise Price in effect immediately
prior to the rise to such adjustment. Whenever any such adjustment is required to be made, the Company shall forthwith determine
the new number of Shares that the Holder hereof shall be entitled to purchase hereunder and/or such new Exercise Price and shall
prepare, retain on file and transmit to the Holder within ten (10) days after such preparation a statement describing in reasonable
detail the method used in calculating such adjustment.


 



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2.6               
No Fractional Shares. The Company shall not issue any fraction of a Share
in connection with the exercise of this Warrant, and in any case where the Holder would, except for the provisions of this Section
2.6, be entitled under the terms of this Warrant to receive a fraction of a Share upon such exercise, the Company shall upon the
exercise and receipt of the Exercise Price, issue the largest number of whole Shares purchasable upon exercise of this Warrant.
The Company shall not be required to make any cash or other adjustment in respect of such fraction of a Share to which the Holder
would otherwise be entitled. The Holder, by the acceptance of this Warrant, expressly waives his right to receive a certificate
for any fraction of a Share upon exercise hereof.


 


2.7               
No Change in Form Required. The form of Warrant need not be changed because
of any change pursuant to this Section 2 in the Exercise Price or in the number of Shares purchasable upon the exercise of a Warrant,
may state the same Exercise Price and the same number of shares of Common Stock as are stated in the Warrants initially issued
pursuant to the Agreement.


 


		3.	Registration Under the Securities Act of 1933.



 


3.1               
Registration and Legends. The Holder understands that (i) the Company
has not registered the Warrant or the Shares under the Act, or the applicable securities laws of any state in reliance on exemptions
from registration and (ii) such exemptions depend upon the Holder’s investment intent at the time the Holder acquires the Warrant
or the Shares. The Holder therefore represents and warrants that it is acquiring the Warrant, and will acquire the Shares, for
the Holder’s own account for investment and not with a view to distribution, assignment, resale or other transfer of the Warrant
or the Shares. Because the Warrant and the Shares are not registered, the Holder is aware that the Holder must hold them indefinitely
unless they are registered under the Act and any applicable securities laws or the Holder must obtain exemptions from such registration.
Upon exercise, in part or in whole, of this Warrant, the Shares shall bear the following legend:


 


The
shares of Common Stock represented by this certificate have not been registered under the Securities Act of 1933, as amended (“Act”)
or any applicable state securities laws, and they may not be offered for sale, sold, transferred, pledged or hypothecated without
an effective registration statement under the Securities Act and under any applicable state securities laws, or an opinion of
counsel, satisfactory to the Company, that an exemption from such registration is available.


 


3.2               
No-Action Letter. The Company agrees that it will be satisfied that no post-effective
amendment or new registration is required for the public sale of the Shares if it shall be presented with a letter from the Staff
of the Securities and Exchange Commission (the “Commission”), stating in effect that, based upon stated facts which the
Company shall have no reason to believe are not true in any material respect, the Staff will not recommend any action to the Commission
if such Shares are offered and sold without delivery of a prospectus, and that, therefore, no Registration Statement under which
such shares are to be registered is required to be filed.


 






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3.3               
Agreements. The agreements in this Section shall continue in effect regardless
of the exercise and surrender of this Warrant. 


 


4.                 Reservation of Shares. The Company shall at all times reserve, for the purpose of issuance
on exercise of this Warrant such number of shares of Common Stock or such class or classes of capital stock or other securities
as shall from time to time be sufficient to comply with this Warrant and the Company shall take such corporate action as may, in
the opinion of its counsel, be necessary to increase its authorized and unissued Common Stock or such other class or classes of
capital stock or other securities to such number as shall be sufficient for that purpose.


 


5.                 Survival. All agreements, covenants, representations and warranties herein shall survive
the execution and delivery of this Warrant and any investigation at any time made by or on behalf of any parties hereto and the
exercise, sale and purchase of this Warrant (and any other securities or property) issuable on exercise hereof.


 


6.                 Remedies. The Company agrees that the remedies at law of the Holder, in the event of
any default or threatened default by the Company in the performance or compliance with any of the terms of this Warrant, may not
be adequate and such terms may, in addition to and not in lieu of any other remedy, be specifically enforced by a decree of specific
performance of any agreement contained herein or by an injunction against a violation of any of the terms hereof or otherwise.


 


7.                 Representations and Warranties by the Holder. The Holder, by its acceptance of this
Warrant, represents and warrants to the Company as follows:


 


7.1               
This Warrant and the Shares issuable upon exercise thereof are being acquired for its own
account, for investment and not with a view to, or for resale in connection with, any distribution or public offering thereof within
the meaning of the Act. Upon exercise of this Warrant, the Holder shall, if so requested by the Company, confirm in writing, in
a form satisfactory to the Company, that the securities issuable upon exercise of this Warrant are being acquired for investment
and not with a view toward distribution or resale;


 


7.2               
The Holder understands that the Warrant and the Shares have not been registered under the
Act or any applicable state securities laws by reason of their issuance in a transaction exempt from the registration and prospectus
delivery requirements of the Act pursuant to Section 4(2) thereof, and that they must be held by the Holder indefinitely,
and that the Holder must therefore bear the economic risk of such investment indefinitely, unless a subsequent disposition thereof
is registered under the Act or any applicable state securities laws or is exempted from such registration;


 


7.3               
The Holder has such knowledge and experience in financial and business matters that it is
capable of evaluating the merits and risks of the purchase of this Warrant and the Shares purchasable pursuant to the terms of
this Warrant and of protecting its interests in connection therewith;


 


7.4               
The Holder is able to bear the economic risk of the purchase of the Shares pursuant to the
terms of this Warrant; and


 



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7.5               
The Holder is an “accredited investor” as such term is defined in Rule 501 of
Regulation D promulgated under the Act.


 


		8.	Other Matters.



 


8.1               
Binding Effect. All the covenants and provisions of this Warrant by or
for the benefit of the Company shall bind and inure to the benefit of its successors and assigns hereunder.


 


8.2               
Notices. All notices or demands provided for in this Warrant shall be
validly given if in writing and delivered personally, sent by certified mail, postage prepaid, or sent via an express delivery
service, such as Federal Express or United Parcel Service, to one party by the other party to the address set forth in this Warrant
or to such other address as each party may from time to time designate in writing. The Company’s address is:


 


Infinity Energy Resources, Inc.


11900 College Blvd., Suite 310


Overland Park, KS 66210


Attn: President


 


Holder’s address is set forth in the first
paragraph of this Warrant.


 


8.3               
Governing Law. The validity, interpretation and performance of this Warrant
shall be governed by the laws of the State of Delaware. 


 


8.4               
Parties Bound and Benefitted. Nothing in this Warrant expressed and nothing
that may be implied from any of the provisions hereof is intended, or shall be construed, to confer upon, or give to, any person
or corporation other than the Company and the Holder any right, remedy or claim under promise or agreement hereof, and all covenants,
conditions, stipulations, promises and agreements contained in this Warrant shall be for the sole and exclusive benefit of the
Company and its successors and of the Holder, its successors and, if permitted, its assignees.


 


8.5               
Headings. The Article headings herein are for convenience only and are
not part of this Warrant and shall not affect the interpretation thereof.


 


IN WITNESS WHEREOF, this
Warrant has been duly executed by the Company under its corporate seal as of February ___, 2013.


 


	 	INFINITY ENERGY RESOURCES, INC.
	 	 	 
		By:	/s/ Stanton E. Ross
	 	 	Stanton E. Ross
	 	Its:	resident and Chief Executive Officer


 



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INFINITY
ENERGY RESOURCES, INC.


 


Assignment


 


FOR VALUE RECEIVED, _____________________________________
hereby sells, assigns and transfers unto _______________________________________________________ the within Warrant and the rights represented thereby, and does hereby irrevocably constitute and appoint ______________________________________
Attorney, to transfer said Warrant on the books of the Company, with full power of substitution.


 


	Dated: ______________________________	 	 
	 	 	 
	 	Signed:	 
	 	Print Name:	 


 



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Subscription
Form


 


Infinity
Energy Resources, Inc. 


11900
College Blvd., Suite 310

Overland Park, KS 66210


 


The undersigned hereby
irrevocably subscribes for the purchase of ________________ shares of Common Stock (the “Shares”), pursuant to
and in accordance with the terms and conditions of this Warrant, and herewith makes payment, covering the purchase of the Shares,
which should be delivered to the undersigned at the address stated below, and, if such number of Shares shall not be all of the
Shares purchasable hereunder, then a new Warrant of like tenor for the balance of the remaining Shares purchasable under this Warrant
be delivered to the undersigned at the address stated below.


 


The undersigned agrees
that: (1) the undersigned will not offer, sell, transfer or otherwise dispose of any such Shares, unless either (a) a registration
statement, or post-effective amendment thereto, covering such Shares have been filed with the Securities and Exchange Commission
pursuant to the Securities Act of 1933, as amended (the “Act”), and such sale, transfer or other disposition is
accompanied by a prospectus meeting the requirements of Section 10 of the Act forming a part of such registration statement,
or post-effective amendment thereto, which is in effect under the Act covering the Shares to be so sold, transferred or otherwise
disposed of, or (b) counsel to the Company satisfactory to the undersigned has rendered an opinion in writing and addressed to
the Company that such proposed offer, sale, transfer or other disposition of the Shares is exempt from the provisions of Section
5 of the Act in view of the circumstances of such proposed offer, sale, transfer or other disposition; (2) the Company may notify
the transfer agent for its Common Stock that the certificates for the Common Stock acquired by the undersigned are not to be transferred
unless the transfer agent receives advice from the Company that one or both of the conditions referred to in (1)(a) and (1)(b)
above have been satisfied; and (3) the Company may affix the legend set forth in Section 3.1 of this Warrant to the certificates
for Shares hereby subscribed for, if such legend is applicable.


 


	Dated: _____________________________	Signed:	 
	 	Address:	 


 



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