Document:

exv10w64

Exhibit 10.64

April 6, 2009

Mr. Wayne Levin

Dear Mr. Levin:

     Reference is hereby made to that certain Amended and Restated Employment Agreement, dated
December 15, 2008 (the “Employment Agreement”), between you and Lions Gate Films, Inc. (the
“Company”). The purpose of this letter agreement is to amend the Employment Agreement as follows:

     1. The first two paragraphs of Section 1 of the Employment Agreement are hereby amended and
restated to read in their entirety as follows:

     “1. The term of this Agreement will begin April 1, 2009 (the “Effective Date”) and end
March 31, 2013, subject to early termination as provided in this Agreement (the “Term”).
Employee’s title shall be General Counsel and Executive Vice President of Corporate
Operations, and such other operational title as shall be agreed upon in good faith by
Employee and the Chief Executive Officer of the Company. In Employee’s capacity as General
Counsel, Employee shall report to the Chief Executive Officer; in Employees operational
capacity, Employee shall report to the Chief Executive Officer or his designee, but no less
than to the Chief Operating Officer. Employee shall render such services as are customarily
rendered by persons in Employee’s capacity in the motion picture industry and as may be
reasonably requested by the Company.”

     2. Section 2(a) of the Employment Agreement is hereby amended and restated to read in its
entirety as follows:

     ”(a) Base Salary. During the Term of this Agreement, the Company agrees to pay
Employee base salary at an annual rate of $750,000 (“Base Salary”), payable in accordance
with the Company’s normal payroll practices in effect. Nothing in this Agreement shall
limit the Company’s right to modify its payroll practices, as it deems necessary.”

     3. The first sentence of Section 2(b)(v) of the Employment Agreement is hereby amended to
provide that for purposes of the Employment Agreement, the term “Change of Control” shall have the
same meaning as set forth in the employment agreement of Michael Burns with the Company as in
effect on the date hereof, with the clarification that what was intended under clause (i) of such
definition is that the term “person” shall include a combination of persons acting in concert and
that an acquisition of securities contemplated by such clause (i) need not occur within the context
of a merger, consolidation, sale or other disposition of equity interests or assets of Lions Gate.

     4. Section 5 of the Employment Agreement is hereby amended and restated to read in its
entirety as follows:

     “5. The Company shall request that the Compensation Committee (the “Committee”) of
Lions Gate Entertainment Corp. (“Lions Gate”) authorize and grant Employee (1) an award of
share appreciation rights with respect to 700,000 common shares of Lions Gate (the “SARs”),
with 50% of the SARs to vest in four equal annual installments after the grant date (with
the last installment to vest on March 29, 2013) and 50% of the SARs to vest over a four-year
period (with the last installment to vest on March 29, 2013), subject to such
performance-based vesting requirements as established by the Company’s Chief Executive
Officer (in consultation with Employee) and approved by the Committee, and (2) an award of
400,000 restricted share units with respect to common shares of Lions Gate (the “Restricted
Share Units”), with 50% of the Restricted Share Units to vest in four equal

1

 

annual installments after the grant date (with the last installment to vest on March
29, 2013) and 50% of the Restricted Share Units to vest equally over a four-year period
(with the last installment to vest on March 29, 2013), subject to such performance-based
vesting requirements as established by the Company’s Chief Executive Officer (in
consultation with Employee) and approved by the Committee. The performance-based SARs and
Restricted Share Units shall vest on a sliding scale basis if the personal performance
targets have not been fully met for a particular year. For purpose of example only, if
seventy-five percent (75%) of the personal performance targets have been met for a
particular year, seventy-five percent (75%) of the grant for that year would vest.
Notwithstanding the foregoing, the Committee may, in its sole discretion, provide that any
or all of the performance-based SARs and Restricted Share Units scheduled to vest on any
such vesting date shall be deemed vested as of such date even if the applicable performance
targets are not met. Furthermore, the Committee may, in its sole discretion, provide that
any of the performance-based SARs and Restricted Share Units scheduled to vest on any such
vesting Date that do not vest because the applicable performance targets are not met may
vest on any future vesting date if the performance targets applicable to such vesting date
are exceeded. The SARs and Restricted Share Units shall be granted under and subject to the
terms of Lions Gate’s 2004 Performance Incentive Plan (the “Plan”) and the applicable award
agreement. The award date (“Award Date”) shall be the date of the Committee meeting at
which such grants are approved, with the per-share base price of the SARs to be the closing
price of Lions Gate common shares on the Award Date. The SARs will be settled in cash and
have a maximum term of five years. Employee acknowledges that such grants are subject to
the approval of the Committee.

     If any employee’s stock options, SARs or shares that are issued under the Plan
accelerate in vesting schedule as a result of a Change of Control, Employee’s previously
granted and outstanding stock options, share appreciation rights and restricted share units
(including any then-outstanding portion of the SARs and/or the Restricted Share Units) shall
likewise accelerate in vesting schedule. If Employee is terminated without cause or a Change
of Control occurs, all RSUs and SARs granted herein shall immediately vest.

     Employee represents and warrants that, during the Term, Employee shall hold at least
5,000 common shares of Lions Gate.”

     5. The penultimate sentence of Section 7(f) of the Employment Agreement is hereby amended and
restated to read in its entirety as follows:

     “(v) For these purposes, if the Company is purchased by a larger entity, it shall not
be considered a material diminution in responsibility if Employee is made either (i) General
Counsel at that larger entity or (ii) the same operational title as agreed to by the Chief
Executive Officer and Employee under this Agreement with the same reporting structure.”

     Except as expressly set forth above, this letter agreement does not modify any other terms of
your Employment Agreement. If this letter accurately sets forth our agreement with respect to the
foregoing matters, please sign the enclosed copy of this letter and return it to me. Please
contact me at                      if you have any questions.

	 	 	 	 	 
	 	Sincerely,

 	 
	 	/s/ Jon Feltheimer
 	 
	 	Chief Executive Officer 	 
	 	 	 
	 

Acknowledged and Agreed:

	 	 	 	 	 
	By:

	 	/s/ Wayne Levin
	 	 
	 

	 	 	 	 
	 

	 	Wayne Levin	 	 

2exv4w15

Exhibit 4.15

NEITHER THIS WARRANT NOR THE SECURITIES ISSUABLE UPON THE EXERCISE HEREOF HAVE BEEN REGISTERED
UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR ANY STATE SECURITIES LAWS
AND MAY NOT BE OFFERED, SOLD, PLEDGED, ASSIGNED, OR OTHERWISE TRANSFERRED UNLESS (1) A REGISTRATION
STATEMENT WITH RESPECT THERETO IS EFFECTIVE UNDER THE SECURITIES ACT AND ANY APPLICABLE STATE
SECURITIES LAWS, OR (2) THE COMPANY RECEIVES AN OPINION OF COMPANY COUNSEL THAT THIS WARRANT OR
SUCH SECURITIES, AS APPLICABLE, MAY BE OFFERED, SOLD, PLEDGED, ASSIGNED, OR OTHERWISE TRANSFERRED
IN THE MANNER CONTEMPLATED WITHOUT AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR
APPLICABLE STATE SECURITIES LAWS.

OCULUS INNOVATIVE SCIENCES, INC.

Form of Warrant for the Purchase of

Shares of Common Stock, Par Value $0.0001 per Share

No.                     

Issue Date:                     

     THIS CERTIFIES that, for consideration, the receipt and sufficiency of which are hereby
acknowledged, and other value received,                                          (the “Holder”) is entitled to
subscribe for, and purchase from, OCULUS INNOVATIVE SCIENCES, INC., a Delaware corporation (the
“Company”), upon the terms and conditions set forth herein, at any time or from time to time six
months after the date this warrant is issued (the “Initial Exercise Date”) until five years after
the Issue Date (the “Exercise Period”), up to an aggregate of                      shares of common stock,
par value $0.0001 per share (the “Common Stock”), of the Company. This Warrant is initially
exercisable at a price of $                     per share, subject to adjustment as described in this Warrant.
The term “Exercise Price” shall mean, depending on the context, the initial exercise price (as set
forth above) or the adjusted exercise price per share. The Company may, in its sole discretion,
reduce the then current Exercise Price to any amount or extend the Exercise Period, at any time.
Such modifications to the Exercise Price or Exercise Period may be temporary or permanent.

     As used herein, the term “this Warrant” shall mean and include this Warrant and any Warrant or
Warrants hereafter issued as a consequence of the exercise or transfer of this Warrant in whole or
in part. Each share of Common Stock issuable upon the exercise hereof shall be hereinafter
referred to as a “Warrant Share.”

          1. (a) Subject to the terms of this Warrant, this Warrant may be exercised at any time in
whole and from time to time in part, at the option of the Holder, on or after the Initial Exercise
Date and on or prior to the end of the Exercise Period. This Warrant shall initially be
exercisable in whole or in part for that number of fully paid and

 

 

nonassessable shares of Common Stock as indicated on the first page of this Warrant, for an
exercise price per share equal to the Exercise Price, by delivery to the Company at its office at
1129 North McDowell Blvd., Petaluma, California 94954, or at such other place as is designated in
writing by the Company, of:

     (i) a completed Election to Purchase, in the form set forth in Exhibit A,
executed by the Holder exercising all or part of the purchase rights represented by this
Warrant;

     (ii) this Warrant; and

     (iii) subject to Section 1(c) below, payment of an amount equal to the product of the
Exercise Price multiplied by the number of shares of Common Stock being purchased upon such
exercise in the form of, at the Holder’s option, (A) a certified or bank cashier’s check
payable to the Company, or (B) a wire transfer of funds to an account designated by the
Company.

     (b) As used herein:

     (i) “Fair Market Value” of a security shall mean, on any given day, the average of the
last reported sale prices for the last ten (10) trading days as officially reported by the
principal securities exchange or “over the counter” (including on the pink sheets or
bulletin board) exchange on which the Common Stock is listed or admitted to trading, or, if
the Common Stock is not listed or admitted to trading on any national securities exchange or
sold “over the counter,” the average closing sale price as furnished by the NASD through
Nasdaq or similar organization if Nasdaq is no longer reporting such information, or if the
Common Stock is not quoted on Nasdaq, as determined in good faith by resolution of the Board
of Directors of the Company, the “Fair Market Value” shall be as determined by the Board of
Directors of the Company in good faith, absent manifest error.

     (c) Cashless Exercise. If at any time six months after the date of the issuance of
this Warrant there is no effective registration statement registering, or no current prospectus
available for, the resale of the Warrant Shares by the Holder, then this Warrant may also be
exercised only at such time by means of a “cashless exercise” in which the Holder shall be entitled
to receive, without the payment by the Holder of any additional consideration, a certificate for
the number of Warrant Shares equal to the number as is computed using the following formula:

where

X = the number of Warrant Shares to be issued to the Holder pursuant to this
Warrant.

 

 

Y = the number of Warrant Shares covered by this Warrant with respect to which the
cashless exercise election is made pursuant to this Section 1(c).

A = the Fair Market Value (as defined above) of one Warrant Share.

B = the Exercise Price in effect at the time the cashless exercise election is made
pursuant to this Section 1(c).

     (d) Upon the exercise of this Warrant, the Company shall issue and cause promptly to be
delivered upon such exercise to, or upon the written order of, the Holder a certificate or
certificates for the number of full Warrant Shares to which such Holder shall be entitled, together
with cash in lieu of any fraction of a Warrant Share otherwise issuable upon such exercise.

     (e) If this Warrant is exercised in respect of less than all of the Warrant Shares evidenced
by this Warrant at any time prior to the end of the Exercise Period, a new Warrant evidencing the
remaining Warrant Shares shall be issued to the Holder, or its nominee(s), without charge therefor.

     (f) In the event that this Warrant is not exercised in full on the last business day of the
Exercise Period, the remaining portion of the Warrant will automatically be exercised as described
in Section 1(c) above.

     2. The Exercise Price for the Warrants in effect from time to time shall be subject to
adjustment as follows:

     (a) If the Company, at any time while this Warrant is outstanding: (i) subdivides outstanding
shares of Common Stock into a larger number of shares, (ii) combines (including by way of reverse
stock split) outstanding shares of Common Stock into a smaller number of shares, or (iii) issues by
reclassification of shares of the Common Stock any shares of capital stock of the Company, then in
each case the Exercise Price shall be multiplied by a fraction of which the numerator shall be the
number of shares of Common Stock (excluding treasury shares, if any) outstanding immediately before
such event and of which the denominator shall be the number of shares of Common Stock outstanding
immediately after such event. Any adjustment made pursuant to this Section 2(a) shall become
effective immediately after the record date for the determination of stockholders entitled to
receive such dividend or distribution and shall become effective immediately after the effective
date in the case of a subdivision, combination or re-classification.

     (b) If the Company, at any time while this Warrant is outstanding, shall distribute to all or
substantially all holders of Common Stock (and not to the Holder) evidence of its indebtedness or
assets (including cash and cash dividends) or rights or warrants to subscribe for or purchase any
security other than the Common Stock, then in each such case the Exercise Price shall be adjusted
by multiplying the Exercise Price in effect immediately prior to the record date fixed for
determination of stockholders entitled to receive such distribution by a

 

 

fraction of which (i) the denominator shall be the Fair Market Value per share of Common Stock
determined as of the record date mentioned above and (ii) the numerator shall be such Fair Market
Value per share of Common Stock on such record date less the then per share fair market value at
such record date of the portion of such evidence of indebtedness or assets (including cash and cash
dividends) or rights or warrants to subscribe for or purchase any security other than the Common
Stock so distributed applicable to one outstanding share of the Common Stock, which fair market
value shall be reduced by the fair market value of consideration, if any, paid to the Company by
holders of Common Stock in exchange for such evidence of indebtedness or assets or rights or
warrants so distributed, in each case as such Fair Market Value is determined by the Board of
Directors of the Company in good faith. In either case, the adjustments shall be described in a
statement provided to the Holder of the portion of evidences of indebtedness or assets (including
cash and cash dividends) or rights or warrants to subscribe for or purchase any security other than
the Common Stock so distributed or such subscription rights applicable to one share of Common
Stock. Such adjustment shall be made whenever any such distribution is made and shall become
effective immediately after the record date mentioned above.

     (c) All calculations under this Section 2 shall be made to the nearest cent.

     (d) The Company shall not be required upon the exercise of this Warrant to issue any
fractional shares, but may pay the value thereof to the Holder in cash on the basis of the Fair
Market Value per Warrant Share.

     3. Unless registered, the Warrant Shares issued on exercise of the Warrants shall be subject
to a stop transfer order and the certificate or certificates representing the Warrant Shares shall
bear the following legend:

THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933,
AS AMENDED (THE “SECURITIES ACT”), OR ANY STATE SECURITIES LAWS AND MAY NOT BE OFFERED,
SOLD, PLEDGED, ASSIGNED, OR OTHERWISE TRANSFERRED UNLESS (1) A REGISTRATION STATEMENT WITH
RESPECT THERETO IS EFFECTIVE UNDER THE SECURITIES ACT AND ANY APPLICABLE STATE SECURITIES
LAWS, OR (2) THE COMPANY RECEIVES AN OPINION OF COUNSEL WHICH COUNSEL AND OPINION ARE
REASONABLY SATISFACTORY TO THE COMPANY, THAT THE SECURITIES MAY BE OFFERED, SOLD, PLEDGED,
ASSIGNED, OR OTHERWISE TRANSFERRED IN THE MANNER CONTEMPLATED WITHOUT AN EFFECTIVE
REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR APPLICABLE STATE SECURITIES LAWS.

     4. 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 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, in the case of the Warrant, shall not

 

 

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,
without charge, of like date, tenor and denomination, in lieu of such Warrant or stock certificate.

     5. The Company shall not be obligated to issue any shares of Common Stock upon exercise of
this Warrant if the issuance of such shares of Common Stock would cause a breach or violation of
the Company’s obligations under any applicable rules or regulations of any market on which the
Company’s securities trade.

     6. The Company shall not effect any exercise of this Warrant, and a Holder shall not have the
right to exercise any portion of this Warrant, to the extent that after giving effect to such
issuance after exercise, such Holder (together with such Holder’s affiliates, and any other person
or entity acting as a group together with such Holder or any of such Holder’s affiliates), would
beneficially own in excess of the Beneficial Ownership Limitation (as defined below). For purposes
of the foregoing sentence, the number of shares of Common Stock beneficially owned by such Holder
and its affiliates shall include the number of shares of Common Stock issuable upon exercise of
this Warrant with respect to which such determination is being made, but shall exclude the number
of shares of Common Stock which would be issuable upon (A) exercise of the remaining, nonexercised
portion of this Warrant beneficially owned by such Holder or any of its affiliates and (B) exercise
or conversion of the unexercised or nonconverted portion of any other securities of the Company
subject to a limitation on conversion or exercise analogous to the limitation contained herein
beneficially owned by such Holder or any of its Affiliates. Except as set forth in the preceding
sentence, beneficial ownership shall be calculated in accordance with Section 13(d) of the
Securities Exchange Act of 1934 and the rules and regulations promulgated thereunder. The
“Beneficial Ownership Limitation” shall be 4.99% of the number of shares of the Common Stock
outstanding immediately after giving effect to the issuance of shares of Common Stock issuable upon
exercise of this Warrant. The Beneficial Ownership Limitation provisions of this section may be
waived by such Holder, at the election of such Holder, upon not less than 61 days’ prior notice to
the Company to change the Beneficial Ownership Limitation to 9.99% of the number of shares of the
Common Stock outstanding immediately after giving effect to the issuance of shares of Common Stock
upon exercise of this Warrant, and the provisions of this section shall continue to apply. Upon
such a change by a Holder of the Beneficial Ownership Limitation from such 4.99% limitation to such
9.99% limitation, the Beneficial Ownership Limitation may not be further waived by such Holder.
The provisions of this paragraph shall be construed and implemented in a manner otherwise than in
strict conformity with the terms of this section to correct this paragraph (or any portion hereof)
which may be defective or inconsistent with the intended Beneficial Ownership Limitation herein
contained or to make changes or supplements necessary or desirable to properly give effect to such
limitation. The limitations contained in this paragraph shall apply to a successor holder of this
Warrant.

     7. (a) The Holder shall not have, solely on account of its status as a holder of a Warrant,
any rights of a stockholder of the Company, either at law or in equity, or to any notice

 

 

of meetings of stockholders or of any other proceedings of the Company, except as provided in
this Warrant.

          (b) No provision hereof, in the absence of affirmative action by the Holder to receive Warrant
Shares, and no enumeration herein of the rights or privileges of the Holder hereof, shall give rise
to any liability of the Holder for the purchase price of any Common Stock or as a stockholder of
Company, whether such liability is asserted by Company or by creditors of Company.

     8. All notices that are required or permitted hereunder shall be in writing and shall be
sufficient if personally delivered, sent by facsimile, or sent by registered or certified mail or
Federal Express or other nationally recognized overnight delivery service. Any notices shall be
deemed given upon the earlier of the date when received at, the day when delivered via facsimile or
the third day after the date when sent by registered or certified mail or the day after the date
when sent by Federal Express to, the address set forth below, unless such address is changed by
notice to the other party hereto:

if to the Company:

Oculus Innovative Sciences, Inc.

1129 North McDowell Blvd.

Petaluma, California 94954

Attention: Jim Schutz, Vice President Corporate Development and General Counsel

Fax: (707) 283-0551

if to the Holder: As set forth in the Warrant Register of the Company.

          The Company or the Holder by notice to the other party may designate additional or different
addresses as shall be furnished in writing by such party.

     9. The provisions of this Warrant may not be amended, modified or changed except by an
instrument in writing signed by each of the Company and the Holder.

     10. All the covenants and provisions of this Warrant by or for the benefit of the Company or
the Holder shall be binding upon and shall inure to the benefit of their respective permitted
successors and assigns hereunder.

     11. The validity, interpretation and performance of this Warrant shall be governed by the laws
of the State of California, as applied to contracts made and performed within such State, without
regard to principles of conflicts of law.

     12. The provisions hereof have been and are made solely for the benefit of the Company and the
Holder, and their respective successors and assigns, and no other person shall acquire or have any
right hereunder or by virtue hereof.

 

 

     13. The headings in this Warrant are for convenience only and shall not limit or otherwise
affect the meaning hereof.

     14. If any term, provision, covenant or restriction of this Warrant is held by a court of
competent jurisdiction to be invalid, illegal, void or unenforceable, the remainder of the terms,
provisions, covenants and restrictions set forth herein shall remain in full force and effect and
shall in no way be affected, impaired or invalidated, and the parties shall use their best efforts
to find and employ an alternative means to achieve the same or substantially the same result as
that contemplated by such term, provision, covenant or restriction. It is hereby stipulated and
declared to be the intention of the parties that they would have executed the remaining terms,
provisions, covenants and restrictions without including any of such which may be hereafter
declared invalid, illegal, void or unenforceable.

     15. This Warrant is intended by the parties as a final expression of their agreement and
intended to be a complete and exclusive statement of the agreement and understanding of the parties
hereto in respect of the subject matter contained herein and therein. There are no restrictions,
promises, warranties or undertakings, other than those set forth or referred to herein and therein.
This Warrant supersedes all prior agreements and understandings between the parties with respect
to such subject matter.

     16. The Company agrees to take such further action and to deliver or cause to be delivered to
each other after the date hereof such additional agreements or instruments as any of them may
reasonably request for the purpose of carrying out this Warrant and the agreements and transactions
contemplated hereby and thereby.

     17. Each party hereto acknowledges and agrees that irreparable harm, for which there may be no
adequate remedy at law and for which the ascertainment of damages would be difficult, would occur
in the event any of the provisions of this Warrant were not performed in accordance with its
specific terms or were otherwise breached. Each party hereto accordingly agrees that each other
party hereto shall be entitled to an injunction or injunctions to prevent breaches of the
provisions of this Warrant, or any agreement contemplated hereunder, and to enforce specifically
the terms and provisions hereof or thereof in any court of the United States or any state thereof
having jurisdiction, in each instance without being required to post bond or other security and in
addition to, and without having to prove the inadequacy of, other remedies at law.

[signature page follows]

 

 

	 	 	 	 	 	 	 
	 	 	Dated as of:	 	 
	 
	 	 	 	 	 	 
	 	 	OCULUS INNOVATIVE SCIENCES, INC.	 	 
	 
	 	 	 	 	 	 
	 

	 	By:
	 	 	 	 
	 

	 	 	 	 	 	 
	 

	 	 	 	Name:	 	 
	 

	 	 	 	Title:	 	 

 

 

EXHIBIT A

ELECTION TO PURCHASE

     The undersigned hereby irrevocably elects to exercise Warrants represented by this Warrant and
to purchase the shares of Common Stock or other securities issuable upon the exercise of said
Warrants, and requests that Certificates for such shares be issued and delivered as follows:

PORTION OF WARRANT BEING EXERCISED: (check applicable box or fill in number of Warrant Shares):

	 	 	 	 	 
	 

	 	Entire Warrant o	 	 
	 
	 	 	 	 
	 

	 	                                         Warrant Shares	 	 
	 
	 	 	 	 
	ISSUE TO:
	 	 	 	 
	 

	 	 

(Name)
	 	 
	 
	 	 	 	 
	 

	 	 

(Address, Including Zip Code)
	 	 
	 
	 	 	 	 
	 

	 	 

(Social Security or Tax Identification Number)
	 	 
	 
	 	 	 	 
	DELIVER TO:
	 	 	 	 
	 

	 	 

(Name)
	 	 
	 
	 	 	 	 
	 

	 	 

(Address, Including Zip Code)
	 	 

     In payment of the purchase price with respect to this Warrant exercised, the undersigned
hereby either (A) tenders payment of $      by (i) certified or bank cashiers check payable
to the order of the Company o; or (ii) a wire transfer of such funds to an account designated by the
Company o (check applicable box) or (B) hereby provides notice to the Company that the undersigned
is exercising this Warrant pursuant to the Cashless Exercise set forth in Section 1(c) of the
Warrant. If the number of Warrant Shares hereby exercised is fewer than all the Warrant Shares
represented by this Warrant, the undersigned requests that a new Warrant representing the number of
full Warrant Shares not exercised to be issued and delivered as set forth below:

	 	 	 	 	 
	Name of Holder or Assignee:
	 	 	 	 
	 

	 	 

(Please Print)
	 	 

Address:                                                             

 

 

                                                                     
   
       

Signature:                          DATED:                     , 20      

(Signature must conform in all respects to name of holder as specified on the fact of this Warrant)

Signature Guaranteed:

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