Document:

EXHIBIT 10.5

 

NEITHER THIS NOTE NOR ANY SECURITIES THAT
MAY BE ISSUED UPON THE CONVERSION HEREOF HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”),
STATE SECURITIES LAWS, OR LAWS OF ANY FOREIGN JURISDICTION. NEITHER THIS NOTE NOR ANY SUCH SECURITIES MAY BE SOLD, ASSIGNED, OFFERED,
PLEDGED, OR OTHERWISE TRANSFERRED IN THE ABSENCE OF EITHER (I) AN EFFECTIVE REGISTRATION STATEMENT UNDER THE ACT AND STATE SECURITIES
LAWS OR (II) THE COMPANY RECEIVING AN OPINION OF COUNSEL SATISFACTORY TO THE COMPANY STATING THAT SUCH SALE, ASSIGNMENT, OFFER,
PLEDGE, OR OTHER TRANSFER IS EXEMPT FROM THE REGISTRATION AND PROSPECTUS DELIVERY REQUIREMENTS OF THE ACT AND STATE SECURITIES
LAWS.

 

Nano Vibronix,
INC.

 

FORM OF CONVERTIBLE PROMISSORY NOTE

 

	$_____________	November __, 2011

 

Investor: ________________

 

FOR VALUE RECEIVED,
subject to the terms contained herein, the undersigned, Nano Vibronix, Inc., a Delaware corporation (the “Company”),
hereby promises to pay to the order of the investor set forth above (the “Investor”), the amount stated above (the
“Principal Amount”) plus interest thereon calculated from the date hereof until paid in full at the annual rate of
ten percent (10%), compounded annually. The Company shall pay the unpaid Principal Amount and interest accrued hereunder in lawful
money of the United States in full on demand on the earlier of an “Event of Default” (as defined below) or November
15, 2014 (the “Maturity Date”), unless it has been previously converted pursuant to Section. hereof, in which
case all outstanding principal and accrued interest under this Note will be satisfied in full by virtue of such conversion. This
Note is one of the convertible promissory notes issued by the Company in connection with its issuance of approximately $1,537,000
of convertible promissory notes pursuant to that certain Subscription Agreement Series B Convertible Preferred Stock and Warrants,
dated as of ___________, 2009, as amended as of November ___, 2011, by and among the Company, the Investor and the other persons
who have executed as investors thereunder (as such agreement may be amended, supplemented or otherwise modified from time to time,
the “Subscription Agreement”).

 

		1.	Prepayment. This Note may not be prepaid without the prior written consent of the Investor.

 

    	 

    	 

    

 

		2.	Conversion.

 

		a.	Definitions.

 

		i.	“Issuance Conversion Event” shall mean an aggregate investment in the Company of $3,000,000
or more in one transaction or a series of related transactions occurring after the date hereof, in which the Company shall have
issued shares in the Company or securities (including convertible debt) exercisable or convertible into shares in the Company.

 

		ii.	“Entity Conversion Event” shall mean a sale, lease, licensing, exchange or other transfer
by the Company of all or substantially all of the Company’s business assets, sale of all or substantially all of the shares
in the Company, reorganization, or consolidation or merger of the Company into or with any other entity except any such
merger or consolidation involving the Company or a subsidiary in which (A) the shares of the surviving or resulting corporation
(or if the surviving or resulting corporation is a wholly owned subsidiary of another corporation immediately following such merger
or consolidation, the parent corporation of such surviving or resulting corporation) are not listed or traded on any exchange and
(B) the shares of capital stock of the Company outstanding immediately prior to such merger or consolidation continue to represent,
or are converted into or exchanged for shares of capital stock that represent, immediately following such merger or consolidation,
at least a majority, by voting power, of the capital stock of (1) the surviving or resulting corporation or (2) if the surviving
or resulting corporation is a wholly owned subsidiary of another corporation immediately following such merger or consolidation,
the parent corporation of such surviving or resulting corporation.

 

		iii.	“Conversion Price” shall mean $0.199 per share of Series B-2 Participating Convertible
Preferred Stock, par value $.001 per share, of the Company. Such amount shall be appropriately adjusted in the case of a stock
dividend, stock split or combination.

 

		b.	If an Issuance Conversion Event or Entity Conversion Event shall occur prior to the Maturity Date,
this Note (including accrued but unpaid interest) shall automatically be converted, at the Conversion Price, into shares of Series
B-2 Participating Convertible Preferred Stock of the Company, par value $.001 per share.

 

		c.	Election to Convert. At any time prior to the Maturity Date, the Investor may elect by written
notice to the Company and the surrender of this Note to convert this Note (including accrued but unpaid interest), at the Conversion
Price, into shares of Series B-2 Participating Convertible Preferred Stock of the Company, par value $.001 per share.

 

		d.	No Fractional Shares. The Company shall not issue any fractional shares on conversion of
this Note. If on any conversion of this Note a fraction of a share results, the Company shall pay the Investor the cash value of
that fractional share, calculated on the basis of the Conversion Price.

 

		e.	No Rights as Shareholder. This Note does not by itself entitle the Investor to any voting
rights or other rights as a shareholder of the Company.

 

    	2

    	 

    

 

		3.	Event of Default.

 

		a.	“Event of Default” means any of the following:

 

		i.	The failure of the Company to pay when due any amounts due hereunder that remain unpaid ten (10)
business days after the Company receives written notice thereof;

 

		ii.	The Company’s breach of a representation or obligation in the Subscription Agreement which
remains uncured for more than 30 days after the Company receives written notice thereof; or

 

		iii.	The Company shall have entered against it by a court having jurisdiction thereof a decree or order
for relief in respect to the Company in an involuntary case under any applicable bankruptcy, insolvency or other similar law, or
a receiver, liquidator, assignee, custodian, trustee, sequestrator or other similar official will have been appointed for the Company
or for any substantial part of the Company’s property, or the winding up or liquidation of the Company’s affairs will
have been ordered; or the Company will have commenced a voluntary case under any applicable bankruptcy, insolvency or other similar
law, or consent to the entry of an order for such relief in an involuntary case under any such law, or any such involuntary case
will have commenced, and not been dismissed within 90 days, or the Company will have consented to the appointment of or taking
possession by a receiver, liquidator, assignee, trustee, custodian, sequestrator or other similar official for the Company or for
any substantial part of the Company’s property, or make any general assignment for the benefit of creditors.

 

		b.	Upon the occurrence, and at any time during the continuance, of an Event of Default, the Investor,
by notice to the Company, may declare all unpaid principal and interest and all other amounts payable under the Notes to be immediately
due and payable and same shall become immediately due and payable upon such notice without presentment, demand, protest or further
notice of any kind; provided, however, that in the event of the occurrence of an Event of Default specified in subparagraph (iii)
above, this Note, all such interest and other amounts payable to Investor hereunder, shall automatically become due and payable,
without presentment, demand, protest or other notice of any kind.

 

		4.	Usury Savings Clause. The Company and the Investor intend to comply at all times with usury
laws. If at any time such laws would render usurious any amounts due under this Note, then it is the Company’s and the Investor’s
express intention that the Company not be required to pay interest on this Note at a rate in excess of the maximum lawful rate,
that the provisions of this section will control over all other provisions of this Note that appear to be in conflict hereunder,
that such excess amount will be immediately credited to the principal balance of this Note (or, if this Note has been fully paid,
refunded by the Investor to the Company), and the provisions hereof will be immediately reformed and the amounts thereafter decreased,
so as to comply with the then-applicable usury law, but so as to permit the recovery of the fullest amount otherwise due under
this Note.

 

    	3

    	 

    

 

		5.	General Provisions.

 

		a.	Amendments and Waivers. This Note and any term hereof may be amended, waived, discharged
or terminated only by an instrument in writing signed by the Company and the Investor or as otherwise provided in the Subscription
Agreement.

 

		b.	Notices. Any notice required or permitted hereunder shall be given in writing and shall
be deemed effectively given upon personal delivery and if a fax number has been provided, upon delivery (with answerback confirmed),
addressed to a party at its address and the fax number, if any, shown below or at such other address and fax number as such party
may designate by three days advance notice to the other party.

 

Any notice to the Investor shall
be sent to the address set forth on the signature page hereof.

 

	Any notice to the Company shall be sent to:	With a copy to: 
	 	 
	 	Nano Vibronix, Inc.
	Nano Vibronix, Inc.	 
	601 Chestnut Street	Fax:   +972 4 820 2794
	Cedarhurst, NY 11516	 
	Attention: Dr. Harold Jacob	 
	Fax: (516) 569 6872	 

 

		c.	Severability. If any provision of this Note is held to be invalid, illegal, or unenforceable,
the validity, legality and enforceability of the remaining provisions of this Note will not be affected or impaired.

 

		d.	Headings. The descriptive headings of the articles, sections, and subsections of this Note
are for convenience of reference only. They do not constitute a part of this Note and do not affect this Note’s construction
or interpretation.

 

		e.	Governing Law; Jurisdiction. The laws of the State of New York govern all matters arising
out of or relating to this Note, including, without limitation, its interpretation, construction, performance, and enforcement,
without giving effect to such State’s conflicts of law principles or rules of construction concerning the drafter hereof.
Each party hereby irrevocably consents and submits to the jurisdiction of any New York State or United States Federal Court sitting
in the State of New York, County of New York, over any action or proceeding arising out of or relating to this Note and irrevocably
consents to the service of any and all process in any such action or proceeding by registered mail addressed to such party at its
address shown below. Each party further waives any objection to venue in New York and any objection to an action or proceeding
in such state and county on the basis of forum non-conveniens. Each party also waives any right to trial by jury.

 

[Signature Page Follows]

 

    	4

    	 

    

  

The parties are signing
and delivering this Note as of the date stated in the caption of this Note.

 

	 	COMPANY:	 
	 	 	 
	 	NANO VIBRONIX, INC.	 
	 	 	 	 
	 	By:	 	 
	 	 	 	 
	 	INVESTOR:	 
	 	 	 	 
	Investor Address:	 	 
	 	 	 	 
	 	By:	 	 
	 	Name:	 	 
	 	Title:	 	 

 

[Acknowledgment and Receipt of Investor
to Convertible Promissory Note]EXHIBIT 10.6

 

	Void after November 15, 2018	Warrant No. ________

 

This Warrant and any shares acquired
upon the exercise of this Warrant have not been registered under the Securities Act of 1933. This Warrant and such shares may not
be sold or transferred in the absence of such registration or an exemption therefrom under said Act. This Warrant and such shares
may not be transferred except upon the conditions specified in this Warrant, and no transfer of this Warrant or such shares shall
be valid or effective unless and until such conditions shall have been complied with.

 

NANO VIBRONIX, INC.

 

FORM OF SERIES B-2 PARTICIPATING CONVERTIBLE
PREFERRED STOCK PURCHASE WARRANT

 

Nano Vibronix, Inc. (the “Company”), having
its principal office at 601 Chestnut Street, Cedarhurst, NY 11516, hereby certifies that, for value received, _____________ (“Investor”),
or assigns, is entitled, subject to the terms set forth below, to purchase from the Company at any time on, or from time to time
after, November___, 2011 and before 5:00 P.M., New York City time, on November 15 , 2018, or as curtailed in accordance with the
terms hereof (the “Expiration Date”), ______________ fully paid and non-assessable shares of Warrant Shares
of the Company, at the Purchase Price per share of $0.199. The number and character of such shares of Warrant Shares and the Purchase
Price per share are subject to adjustment as provided herein.

 

As used herein, the following terms have the following respective
meanings:

 

“Warrant Shares” means the Series B-2 Participating
Convertible Preferred Stock of the Company Stock, par value $0.001 per share, of the Company.

 

“Exchange Act” means the Securities Exchange
Act of 1934 as the same shall be in effect at the time.

 

“Holder” means any record owner of this Warrant.

 

“Per Share Market Value” has the meaning
set forth in Section 2.3.

 

“Original Issue Date” means November ___,
2011.

 

“Other Securities” refers to any stock (other
than Warrant Shares) and other securities of the Company or any other entity which the Holder of this Warrant at any time shall
be entitled to receive, or shall have received, upon the exercise of this Warrant, in lieu of or in addition to Warrant Shares,
or which at any time shall be issuable or shall have been issued in exchange for or in replacement of Warrant Shares or Other Securities
pursuant to Section 5 or otherwise.

 

    	 

    	 

    

 

“Securities Act” means the Securities Act
of 1933 as the same shall be in effect at the time.

 

“Underlying Securities” means any Warrant
Shares or Other Securities issued or issuable upon exercise of this Warrant.

 

“Warrant” means, as applicable, this Warrant
or each right as set forth in this Warrant to purchase one share of Warrant Shares, as adjusted.

 

1.           Sale
or Exercise Without Registration. If, at the time of any exercise, transfer or surrender for exchange of a Warrant or of Underlying
Securities previously issued upon the exercise of Warrants, such Warrant or Underlying Securities shall not be registered under
the Securities Act, the Company may require, as a condition of allowing such exercise, transfer or exchange, that the Holder or
transferee of such Warrant or Underlying Securities, as the case may be, furnish to the Company an opinion of counsel, reasonably
satisfactory to the Company, to the effect that such exercise, transfer or exchange may be made without registration under the
Securities Act.

 

2.           Exercise
of Warrant.

 

2.1.         Exercise
in Full. Subject to the provisions hereof, this Warrant may be exercised in full by the Holder hereof by surrender of this
Warrant, with the form of subscription at the end hereof duly executed by such Holder, to the Company at its principal office accompanied
by payment, in cash or by certified or official bank check payable to the order of the Company, in the amount obtained by multiplying
the number of shares of Purchase Stock issuable upon exercise of this Warrant by the Purchase Price per share, after giving effect
to all adjustments through the date of exercise.

 

2.2.         Partial
Exercise. Subject to the provisions hereof, this Warrant may be exercised in part by surrender of this Warrant in the manner
and at the place provided in Section 3.1 except that the amount payable by the Holder upon any partial exercise shall be the amount
obtained by multiplying (a) the number of shares of Warrant Shares (without giving effect to any adjustment therein) designated
by the Holder in the subscription at the end hereof, by (b) the Purchase Price per share. Upon any such partial exercise, the Company
at its expense will forthwith issue and deliver to or upon the order of the Holder hereof a new Warrant of like tenor, for the
remaining number of shares of Warrant Shares which may be purchased hereunder.

 

2.3          Cashless Exercise. In addition
to the method of payment set forth in Sections 2.1 and 2.2 and in lieu of any cash payment required thereunder, the Holder of the
Warrant shall have the right at any time and from time to time to exercise the Warrant in full or in part by surrendering this
Warrant in the manner and at the place specified in Section 3.1, specifying the number of shares for which this Warrant is being
exercised. The Company shall issue Holder the number of shares computed using the following formula:

 

    	2

    	 

    

 

	

        X=
	

	 	 	 
	where:	 	X = the number of Underlying Securities to be issued to Holder.
	 	 
	 	 	Y = the number of Underlying Securities for which this Warrant is being exercised.
	 	 
	 	 	A = the Purchase Price.
	 	 
	 	 	B = the Per Share Market Value of one share of Underlying Securities on the business day immediately preceding the date of such election

 

 

“Per
Share Market Value” means on any particular date (a) the closing sales price
per share of the Underlying Securities on such date on any registered national stock exchange
on which the Underlying Securities is then listed, or if there is no such closing sales price
on such date, then the closing sales price on such exchange or quotation system on the date nearest preceding such date, or (b)
if the Underlying Securities is not then listed on a registered national stock exchange, the
closing sales price for a share of Underlying Securities in
the over-the-counter market, as reported by the OTC Bulletin Board or the OTC Markets Group, Inc. (or similar organization or agency
succeeding to its functions of reporting prices) at the close of business on such date, or (c) if the Underlying Securities
is not then reported by the OTC Bulletin Board or the OTC Markets Group, Inc. (or similar organization
or agency succeeding to its functions of reporting prices), the fair market value of a share of Underlying Securities as
determined by the Board, acting in good faith. In determining the fair market value of any shares of Underlying Securities
no consideration shall be given to any restrictions on transfer of the Underlying Securities
imposed by agreement or by federal or state securities laws, or to the existence or absence of, or any limitations on, voting rights.

 

2.4.         Certain
Exercises. If this Warrant is to be exercised in connection with a registered public offering or sale of the Company,
such exercise may, at the election of the Holder, be conditioned on the consummation of the public offering or sale of the
Company, in which case such exercise shall not be deemed effective until the consummation of such transaction.

 

3.           Delivery
of Stock Certificates, etc., on Exercise. As soon as practicable after the exercise of this Warrant in full or in part, the
Company at its own expense (including the payment by it of any applicable issue taxes) will cause to be issued in the name of and
delivered to the Holder hereof, or as such Holder (upon payment by such Holder of any applicable transfer taxes) may direct, a
certificate or certificates for the number of fully paid and non-assessable shares of Warrant Shares or Other Securities to which
such Holder shall be entitled upon such exercise, plus, in lieu of any fractional share to which such Holder would otherwise be
entitled, cash equal to such fraction multiplied by the then-current Market Price of one full share, together with any other stock
or other securities and property (including cash, where applicable) to which such Holder is entitled upon such exercise pursuant
to Section 4 or otherwise.

 

    	3

    	 

    

 

4.           Adjustment
for Dividends in Other Stock, Property, etc.; Reclassification, etc. In case at any time or from time to time after the Original
Issue Date, the holders of Warrant Shares (or, if applicable, Other Securities) shall have received, or (on or after the record
date fixed for the determination of stockholders eligible to receive) shall have become entitled to receive, without payment therefor

 

(a)          other
or additional stock or other securities or property (other than cash) by way of dividend, or

 

(b)          any
cash paid or payable (including, without limitation, by way of dividend), or

 

(c)          other
or additional stock or other securities or property (including cash) by way of spin-off, split-up, reclassification, recapitalization,
combination of shares or similar corporate rearrangement,

 

then, and in each such case the Holder of this Warrant, upon
the exercise hereof as provided in Section 2, shall be entitled to receive the amount of stock and other securities and property
(including cash in the cases referred to in subdivisions (b) and (c) of this Section 4) which such Holder would hold on the date
of such exercise if on the Original Issue Date such Holder had been the Holder of record of the number of shares of Warrant Shares
called for on the face of this Warrant and had thereafter, during the period from the Original Issue Date to and including the
date of such exercise, retained such shares and all such other or additional stock and other securities and property (including
cash in the cases referred to in subdivisions (b) and (c) of this Section 4) receivable by such Holder as aforesaid during such
period, giving effect to all adjustments called for during such period by Section 5 hereof. If the number of shares of Warrant
Shares outstanding at any time after the date hereof is decreased by a combination or reverse stock split of the outstanding shares
of Common Stock, the Purchase Price per share shall be increased, and the number of shares of Warrant Shares purchasable under
this Warrant shall be decreased in proportion to such decrease in outstanding shares of Warrant Shares.

 

5.           Reorganization,
Consolidation, Merger, etc. In case the Company after the Original Issue Date shall (a) effect a reorganization, (b) consolidate
with or merge into any other entity or (c) transfer all or substantially all of its properties or assets to any other entity under
any plan or arrangement contemplating the dissolution of the Company, then, in each such case, the Holder of this Warrant, upon
the exercise hereof as provided in Section 3 at any time after the consummation of such reorganization, consolidation or merger
or the effective date of such dissolution, as the case may be, shall be entitled to receive (and the Company shall be entitled
to deliver), in lieu of the Underlying Securities issuable upon such exercise prior to such consummation or such effective date,
the stock and other securities and property (including cash) to which such Holder would have been entitled upon such consummation
or in connection with such dissolution, as the case may be, if such Holder had so exercised this Warrant immediately prior thereto,
all subject to further adjustment thereafter as provided in this Section 5; provided that if the sole consideration to which such
Holder would have been entitled upon such consummation or in connection with such dissolution, as the case may be, if such Holder
had so exercised this Warrant immediately prior thereto, is cash, the Warrant shall be terminated upon such consummation or dissolution.
The Company shall not effect any such reorganization, consolidation, merger or sale, unless prior to or simultaneously with the
consummation thereof, the successor corporation resulting from such consolidation or merger or the corporation purchasing such
assets or the appropriate corporation or entity shall assume, by written instrument, the obligation to deliver to each Holder the
shares of stock, cash, other securities or assets to which, in accordance with the foregoing provisions, each Holder may be entitled
to and all other obligations of the Company under this Warrant. In any such case, if necessary, the provisions set forth in this
Section 5 with respect to the rights thereafter of the Holders shall be appropriately adjusted so as to be applicable, as nearly
as may reasonably be, to any Other Securities or assets thereafter deliverable on the exercise of the Warrants.

 

    	4

    	 

    

 

6.           Further
Assurances. The Company will take all such action as may be necessary or appropriate in order that the Company may validly
and legally issue fully paid and non-assessable shares of stock upon the exercise of all Warrants from time to time outstanding.

 

7.           Officer's
Certificate as to Adjustments. In each case of any adjustment or readjustment in the shares of Warrant Shares (or Other Securities)
issuable upon the exercise of the Warrants, the Company will issue a certificate setting forth such adjustment or readjustment
and the basis therefor.

 

8.           Notices
of Record Date, etc. In the event of

 

(a)          any
taking by the Company of a record of its stockholders for the purpose of determining the stockholders thereof who are entitled
to receive any dividend or other distribution, or any right to subscribe for, purchase or otherwise acquire any shares of stock
of any class or any other securities or property, or to receive any other right, or for the purpose of determining stockholders
who are entitled to vote in connection with any proposed capital reorganization of the Company, any reclassification or recapitalization
of the capital stock of the Company or any transfer of all or substantially all the assets of the Company to or consolidation or
merger of the Company with or into any other person, or

 

(b)          any
voluntary or involuntary dissolution, liquidation or winding-up of the Company, or

 

(c)          any
proposed issue or grant by the Company of any Common Stock, or any other securities, or any right or option to subscribe for, purchase
or otherwise acquire any shares of stock of any class or any other securities (other than the issue of Common Stock on the exercise
of the Warrants),

 

    	5

    	 

    

 

then and in each such event the Company will mail or cause to
be mailed to each Holder of a Warrant a notice specifying (i) the date on which any such record is to be taken for the purpose
of such dividend, distribution or right, and stating the amount and character of such dividend, distribution or right, (ii) the
date on which any such reorganization, reclassification, recapitalization, transfer, consolidation, merger, dissolution, liquidation
or winding-up is to take place, and the time, if any, as of which the Holders of record of Underlying Securities shall be entitled
to exchange their shares of Underlying Securities for securities or other property deliverable upon such reorganization, reclassification,
recapitalization, transfer, consolidation, merger, dissolution, liquidation or winding-up and (iii) the amount and character of
any stock or other securities, or rights or options with respect thereto, proposed to be issued or granted, the date of such proposed
issue or grant and the persons or class of persons to whom such proposed issue or grant and the persons or class of persons to
whom such proposed issue or grant is to be offered or made. Such notice shall be given at least 10 days prior to the date therein
specified.

 

9.           Reservation
of Stock, etc., Issuable on Exercise of Warrants. The Company will at all times reserve and keep available, solely for issuance
and delivery upon the exercise of the Warrants, all shares of Warrant Shares (or Other Securities) from time to time issuable upon
the exercise of the Warrants.

 

10.         Notices,
etc. All notices and other communications from the Company to the Holder of this Warrant shall be delivered by fax or courier,
at such address as may have been furnished to the Company in writing by such Holder, or, until an address is so furnished, to and
at the address of the last Holder of this Warrant who has so furnished an address to the Company.

 

11.         Miscellaneous.
This Warrant and any term hereof may be changed, waived, discharged or terminated only by an instrument in writing signed by the
Company and the Holder or as otherwise provided in the Subscription Agreement. This Warrant shall be governed by and construed
and enforced in accordance with the General Corporation Law of the State of Delaware without regard to principles of conflicts
of law. Each party hereby irrevocably consents and submits to the jurisdiction of any New York State or United States Federal Court
sitting in the State of New York, County of New York, over any action or proceeding arising out of or relating to this Agreement
and irrevocably consents to the service of any and all process in any such action or proceeding by registered mail addressed to
such party at its address specified herein (or as otherwise noticed to the other party). Each party further waives any objection
to venue in New York and any objection to an action or proceeding in such state and county on the basis of forum non conveniens.
Each party also waives any right to trial by jury.

 

	Dated: __________ __, 2011	 	NANO VIBRONIX, INC.
	 	 	 	By:	 
	 	 	 	Name:
	Attest:	 	 	Title:

 

    	6

    	 

    

 

FORM OF SUBSCRIPTION

 

(To be signed only upon exercise of Warrant)

 

To: NANO VIBRONIX, INC.

 

The undersigned, the Holder of the within
Warrant, hereby irrevocably elects to exercise the purchase right represented by such Warrant for, and to purchase thereunder,
_________ shares of Warrant Shares of Nano Vibronix, Inc., and herewith makes payment therefor

 

(i) of $_____________ or

 

(ii) by surrender of the number of Warrants included
in the within Warrant required for full exercise pursuant to Section 2.3 of the Warrant,

and requests that the certificates for such shares be issued
in the name of, and delivered to, ___________________, whose address is _______________________.

 

	Dated:	 
	 	 
	 	 
	 	(Signature must conform in all respects to name of Holder as specified on the face of the Warrant)
	 	 
	 	 
	 	(Address)

 

    	7

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00227-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00227-of-00352.parquet"}]]