Document:

Exhibit 4.1

 

COMMON STOCK PURCHASE WARRANT

 

To Purchase [          ]
Shares of Common Stock of

 

ACUSPHERE, INC.

 

Date of Issuance:  April     , 2006

 

This
Common Stock Purchase Warrant (this “Warrant”)
certifies that, for value received, [              ]
(the “Holder”), is entitled, upon
the terms and subject to the limitations on exercise and the conditions
hereinafter set forth, at any time on or after October        ,
2006 (the “Initial Exercise Date”)
and on or prior to the close of business on the fifth anniversary of the Date
of Issuance (the “Termination Date”)
but not thereafter, to subscribe for and purchase from Acusphere, Inc., a
Delaware corporation (the “Company”),
up to [             ]
shares (the “Warrant Shares”) of
the Company’s Common Stock, par value $0.01 per share (the “Common Stock”). The purchase price of one
share of Common Stock (the “Exercise Price”)
under this Warrant shall be $7.97. Capitalized terms used and not otherwise
defined herein shall have the meanings set forth in that certain Subscription
Agreement (the “Subscription Agreement”),
dated as of April    , 2006 between the Company and the
Investor. This Warrant is one of a series of warrants issued as of the
date hereof (the “Warrants”)
pursuant to subscription agreements substantially the same as the Subscription
Agreement (the “Subscription Agreements”).

 

1.                                       Title to Warrant. Prior to the Termination Date and subject
to compliance with applicable laws and to the conditions set forth in Section 7
hereof, this Warrant and all rights hereunder are transferable, in whole or in
part, at the office or agency of the Company by the Holder in person or by duly
authorized attorney, upon surrender of this Warrant together with the
Assignment Form annexed hereto properly endorsed.

 

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

 

3.                                       Exercise of Warrant. 

 

(a)                                  Except as provided elsewhere herein, exercise
of the purchase rights represented by this Warrant may be made at any time
or times on or after the Initial Exercise Date until 5:00 p.m. (New York
City time) on the Termination Date by the surrender of this Warrant and the
Notice of Exercise Form annexed hereto (the “Warrant Exercise Documents”) duly executed, at the office of
the Company (or such other office or agency of the Company as it may designate
by notice in writing to the registered Holder at the address of such Holder appearing
on the books of the Company) and upon payment of the Exercise Price of the
shares thereby purchased by wire transfer or cashier’s check drawn on a United
States bank. On or before the third (3rd) business day following the
date on which the Company has received the

 

 

Exercise Price and all of the Warrant Exercise Documents (the “Share Delivery Date”), Certificates for
Warrant Shares purchased hereunder shall be transmitted by the transfer agent
of the Company to the Holder by crediting the account of the Holder’s prime
broker with the Depository Trust Company through its Deposit Withdrawal Agent
Commission (“DWAC”) system if the
Company’s transfer agent is a participant in such system, and otherwise by
physical delivery to the address specified by the Holder in the Notice of
Exercise Form. This Warrant shall be deemed to have been exercised and such
certificate or certificates shall be deemed to have been issued, and Holder or
any other person so designated to be named therein shall be deemed to have
become a holder of record of such shares for all purposes, as of the date the
Warrant has been exercised by payment to the Company of the Exercise Price and
all taxes required to be paid by the Holder, if any, pursuant to Section 5
hereof, prior to the issuance of such shares, have been paid.

 

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

 

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

 

5.                                       Charges, Taxes and Expenses. Issuance of certificates for Warrant Shares
shall be made without charge to the Holder for any issue or transfer tax or
other incidental expense in respect of the issuance of such certificate, all of
which taxes and expenses shall be paid by the Company, and such certificates
shall be issued in the name of the Holder or in such name or names as may be
directed by the Holder; provided, however, that in the event certificates for
Warrant Shares are to be issued in a name other than the name of the Holder,
this Warrant when surrendered for exercise shall be accompanied by the
Assignment Form attached hereto duly executed by the Holder; and the
Company may require, as a condition thereto, the payment of a sum
sufficient to reimburse it for any transfer tax incidental thereto. For
avoidance of doubt, it is understood that taxes based upon income are not
incidental to the issuance of such certificates and shall be the responsibility
of the Holder.

 

6.                                       Closing of Books. The Company will not close its stockholder
books or records in any manner, which prevents the timely exercise of this
Warrant, pursuant to the terms hereof.

 

7.                                       Transfer, Division and Combination.

 

(a)                                  Subject to compliance with any applicable
securities laws and the conditions set forth in Sections 1 and 7(d) hereof,
this Warrant and all rights hereunder are transferable, in whole or in part,
upon surrender of this Warrant at the principal office of the Company, together
with a written assignment of this Warrant substantially in the form attached
hereto duly executed by the Holder or its agent or attorney and funds
sufficient to pay any transfer taxes payable upon the making of such transfer. Upon
such surrender and, if required,

 

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such payment, the Company shall execute and deliver a new Warrant or
Warrants in the name of the assignee or assignees and in the denomination or
denominations specified in such instrument of assignment, and shall issue to
the assignor a new Warrant evidencing the portion of this Warrant not so
assigned, and this Warrant shall promptly be cancelled. A Warrant, if properly
assigned, may be exercised by a new holder for the purchase of Warrant
Shares without having a new Warrant issued.

 

(b)                                 This Warrant may be divided or combined
with other Warrants upon presentation hereof at the aforesaid office of the
Company, together with a written notice specifying the names and denominations
in which new Warrants are to be issued, signed by the Holder or its agent or
attorney. Subject to compliance with Section 7(a), as to any
transfer which may be involved in such division or combination, the
Company shall execute and deliver a new Warrant or Warrants in exchange for the
Warrant or Warrants to be divided or combined in accordance with such notice.

 

(c)                                  The Company shall prepare, issue and deliver
at its own expense (other than transfer taxes) the new Warrant or Warrants
under this Section 7.

 

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

 

8.                                       No Rights as Shareholder until Exercise. This Warrant does not entitle the Holder to
any voting rights or other rights as a shareholder of the Company prior to the
exercise hereof. Upon the surrender of this Warrant and the payment of the
aggregate Exercise Price (or if permitted hereunder, by means of a cashless
exercise), the Warrant Shares so purchased shall be and be deemed to be issued
to such Holder as the record owner of such shares as of the close of business
on the later of the date of such surrender or payment.

 

9.                                       Loss, Theft, Destruction or Mutilation of
Warrant. The Company
covenants that upon receipt by the Company of evidence reasonably satisfactory
to it of the loss, theft, destruction or mutilation of this Warrant 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 of like
tenor and dated as of such cancellation, in lieu of such Warrant or stock
certificate.

 

10.                                 Saturdays, Sundays, Holidays, etc. If the last or appointed day for the taking
of any action or the expiration of any right required or granted herein shall
be a Saturday, Sunday or a legal holiday, then such action may be taken or
such right may be exercised on the next succeeding day not a Saturday,
Sunday or legal holiday.

 

11.                                 Adjustments of Exercise Price and Number of
Warrant Shares. The number
and kind of securities purchasable upon the exercise of this Warrant and the
Exercise Price shall be subject to adjustment from time to time upon the
happening of any of the following. In case the Company shall (i) pay a
dividend in shares of Common Stock or make a distribution in shares of Common
Stock to holders of its outstanding Common Stock, (ii) subdivide its
outstanding shares

 

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of Common Stock into a greater number of shares, (iii) combine its
outstanding shares of Common Stock into a smaller number of shares of Common
Stock, or (iv) issue any shares of its capital stock in a reclassification
of the Common Stock, then the number of Warrant Shares purchasable upon
exercise of this Warrant immediately prior thereto shall be adjusted so that
the Holder shall be entitled to receive the kind and number of Warrant Shares
or other securities of the Company which it would have owned or have been
entitled to receive had such Warrant been exercised in advance thereof. Upon
each such adjustment of the kind and number of Warrant Shares or other
securities of the Company which are purchasable hereunder, the Holder shall
thereafter be entitled to purchase the number of Warrant Shares or other
securities resulting from such adjustment at an Exercise Price per Warrant
Share or other security obtained by multiplying the Exercise Price in effect
immediately prior to such adjustment by the number of Warrant Shares
purchasable pursuant hereto immediately prior to such adjustment, and dividing
such product by the number of Warrant Shares or other securities of the Company
resulting from such adjustment. An adjustment made pursuant to this paragraph
shall become effective immediately after the effective date of such event
retroactive to the record date, if any, for such event.

 

12.                                 Reorganization, Reclassification, Merger,
Consolidation or Disposition of Assets. In case the Company shall reorganize its capital, reclassify its
capital stock, consolidate or merge with or into another corporation (where the
Company is not the surviving corporation or where there is a change in or
distribution with respect to the Common Stock of the Company), or sell,
transfer or otherwise dispose of all or substantially all its property, assets
or business to another corporation and, pursuant to the terms of such
reorganization, reclassification, merger, consolidation or disposition of
assets, shares of common stock of the successor or acquiring corporation, or
any cash, shares of stock or other securities or property of any nature
whatsoever (including warrants or other subscription or purchase rights) in
addition to or in lieu of common stock of the successor or acquiring
corporation (“Other Property”),
are to be received by or distributed to the holders of Common Stock of the Company,
then the Holder shall have the right thereafter to receive upon exercise of
this Warrant, the number of shares of Common Stock of the successor or
acquiring corporation or of the Company, if it is the surviving corporation,
and Other Property receivable upon or as a result of such reorganization,
reclassification, merger, consolidation or disposition of assets by a Holder of
the number of shares of Common Stock for which this Warrant is exercisable
immediately prior to such event. In case of any such reorganization,
reclassification, merger, consolidation or disposition of assets, the successor
or acquiring corporation (if other than the Company) shall expressly assume the
due and punctual observance and performance of each and every covenant and condition
of this Warrant to be performed and observed by the Company and all the
obligations and liabilities hereunder, subject to such modifications as may be
deemed appropriate (as determined in good faith by resolution of the Board of
Directors of the Company) in order to provide for adjustments of Warrant Shares
for which this Warrant is exercisable which shall be as nearly equivalent as
practicable to the adjustments provided for in this Section 12. For
purposes of this Section 12, “common stock of the successor or
acquiring corporation” shall include stock of such corporation of any class which
is not preferred as to dividends or assets over any other class of stock
of such corporation and which is not subject to redemption and shall also
include any evidences of indebtedness, shares of stock or other securities
which are convertible into or exchangeable for any such stock, either
immediately or upon the arrival of a specified date or the happening of a
specified event and any warrants or other rights to subscribe for or purchase
any such stock. The foregoing

 

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provisions of this Section 12 shall similarly apply to
successive reorganizations, reclassifications, mergers, consolidations or
disposition of assets.

 

13.                                 Limitation on Exercise. Notwithstanding anything to the contrary
contained herein, the number of shares of Common Stock that may be
acquired by the Holder upon any exercise of this Warrant (or otherwise in
respect hereof) shall be limited to the extent necessary to insure that,
following such exercise (or other issuance), the total number of shares of
Common Stock then beneficially owned by such Holder and its Affiliates and any
other Persons whose beneficial ownership of Common Stock would be aggregated
with the Holder’s for purposes of Section 13(d) of the Exchange Act,
does not exceed 9.999% of the total number of issued and outstanding shares of
Common Stock (including for such purpose the shares of Common Stock issuable
upon such exercise). For such purposes, beneficial ownership shall be
determined in accordance with Section 13(d) of the Exchange Act and
the rules and regulations promulgated thereunder. Each delivery of an
Exercise Notice hereunder will constitute a representation by the Holder that
it has evaluated the limitation set forth in this paragraph and determined that
issuance of the full number of Warrant Shares requested in such Exercise Notice
is permitted under this paragraph. This provision shall not restrict the number
of shares of Common Stock which a Holder may receive or beneficially own
in order to determine the amount of securities or other consideration that such
Holder may receive in the event of a merger or other business combination
or reclassification involving the Company as contemplated in Section 12
of this Warrant. This restriction may not be waived without the consent of
the Holder.

 

14.                                 Notice of Adjustment. Whenever the number of Warrant Shares or
number or kind of securities or other property purchasable upon the exercise of
this Warrant or the Exercise Price is adjusted, as herein provided, the Company
shall promptly give notice thereof to the Holder, which notice shall state the
number of Warrant Shares (and other securities or property) purchasable upon
the exercise of this Warrant and the Exercise Price of such Warrant Shares (and
other securities or property) after such adjustment, setting forth a brief
statement of the facts requiring such adjustment and setting forth the
computation by which such adjustment was made.

 

15.                                 Notice of Corporate Action. If at any time:  (a) the Company shall take a record of
the holders of its Common Stock for the purpose of entitling them to receive a
dividend or other distribution, or any right to subscribe for or purchase any
evidences of its indebtedness, any shares of stock of any class or any
other securities or property, or to receive any other right, or  (b) there shall be any capital
reorganization of the Company, any reclassification or recapitalization of the
capital stock of the Company or any consolidation or merger of the Company
with, or any sale, transfer or other disposition of all or substantially all
the property, assets or business of the Company to, another corporation or, (c) there
shall be a voluntary or involuntary dissolution, liquidation or winding up of
the Company; then, in any one or more of such cases, the Company shall give to
Holder (i) at least 20 days’ prior written notice of the date on which a
record date shall be selected for such dividend, distribution or right or for
determining rights to vote in respect of any such reorganization,
reclassification, merger, consolidation, sale, transfer, disposition,
liquidation or winding up, and (ii) in the case of any such
reorganization, reclassification, merger, consolidation, sale, transfer,
disposition, dissolution, liquidation or winding up, at least 20 days’ prior
written notice of the date when the same shall take place. Such notice in
accordance with the foregoing clause also shall specify (i)

 

5

 

the date on which any such record is to be taken for the purpose of
such dividend, distribution or right, the date on which the holders of Common
Stock shall be entitled to any such dividend, distribution or right, and the
amount and character thereof, and (ii) the date on which any such
reorganization, reclassification, merger, consolidation, sale, transfer,
disposition, dissolution, liquidation or winding up is to take place and the
time, if any such time is to be fixed, as of which the holders of Common Stock
shall be entitled to exchange their Warrant Shares for securities or other
property deliverable upon such disposition, dissolution, liquidation or winding
up. Each such written notice shall be sufficiently given if addressed to Holder
at the last address of Holder appearing on the books of the Company and
delivered in accordance with Section 18(c).

 

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

 

Except
and to the extent as waived or consented to by the Holder, the Company shall
not by any action, including, without limitation, amending its articles of
organization or through any reorganization, transfer of assets, consolidation,
merger, dissolution, issue or sale of securities or any other voluntary action,
avoid or seek to avoid the observance or performance of any of the terms of
this Warrant, but will at all times in good faith assist in the carrying out of
all such terms and in the taking of all such actions as may be necessary
or appropriate to protect the rights of Holder as set forth in this Warrant
against impairment. Without limiting the generality of the foregoing, the
Company will (a) not increase the par value of any Warrant Shares above
the amount payable therefor upon such exercise immediately prior to such
increase in par value, (b) take all such action as may be necessary
or appropriate in order that the Company may validly and legally issue
fully paid and nonassessable Warrant Shares upon the exercise of this Warrant,
and (c) use commercially reasonable efforts to obtain all such
authorizations, exemptions or consents from any public regulatory body having
jurisdiction thereof as may be necessary to enable the Company to perform its
obligations under this Warrant.

 

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

 

17.                                 Miscellaneous.

 

(a)                                  Jurisdiction. All questions concerning the construction,
validity, enforcement and interpretation of this Warrant shall be governed by
the internal laws of the State of New York, without giving effect to any choice
of law or conflict of law provision or rule

 

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(whether of the State of New York or any other jurisdictions) that
would cause the application of the laws of any jurisdictions other than the
State of New York. Each party hereby irrevocably submits to the non-exclusive
jurisdiction of the state and federal courts sitting in the City of New York,
Borough of Manhattan, for the adjudication of any dispute hereunder or in
connection herewith or with any transaction contemplated hereby or discussed
herein, and hereby irrevocably waives, and agrees not to assert in any suit,
action or proceeding, any claim that it is not personally subject to the
jurisdiction of any such court, that such suit, action or proceeding is brought
in an inconvenient forum or that the venue of such suit, action or proceeding
is improper. Each party hereby irrevocably waives personal service of process
and consents to process being served in any such suit, action or proceeding by
mailing a copy thereof to such party at the address for such notices to it
under this Warrant and agrees that such service shall constitute good and
sufficient service of process and notice thereof. EACH PARTY HEREBY IRREVOCABLY
WAIVES ANY RIGHT IT MAY HAVE, AND AGREES NOT TO REQUEST, A JURY TRIAL FOR
THE ADJUDICATION OF ANY DISPUTE HEREUNDER OR IN CONNECTION HEREWITH OR ARISING
OUT OF THIS WARRANT OR ANY TRANSACTION CONTEMPLATED HEREBY.

 

(b)                                 Nonwaiver. No course of dealing or any delay or failure to exercise any right
hereunder on the part of Holder shall operate as a waiver of such right or
otherwise prejudice Holder’s rights, powers or remedies, notwithstanding all
rights hereunder terminate on the Termination Date.

 

(c)                                  Notices. Any notice, request or other document required or permitted to be
given or delivered to the Holder by the Company shall be delivered in
accordance with the notice provisions of the Subscription Agreement.

 

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

 

(e)                                  Remedies. Holder, in addition to being entitled to exercise all rights granted
by law, including recovery of damages, will be entitled to specific performance
of its rights under this Warrant. The Company agrees that monetary damages
would not be adequate compensation for any loss incurred by reason of a breach
by it of the provisions of this Warrant and hereby agrees to waive the defense
in any action for specific performance that a remedy at law would be adequate.

 

(f)                                    Successors and Assigns. Subject to applicable securities laws, this
Warrant and the rights and obligations evidenced hereby shall inure to the
benefit of and be binding upon the successors of the Company and the successors
and permitted assigns of Holder. The provisions of this Warrant are intended to
be for the benefit of all Holders from time to time of this Warrant and shall
be enforceable by any such Holder or holder of Warrant Shares.

 

(g)                                 Amendment. Except as provided in Section 13, this Warrant may be
modified or amended or the provisions hereof waived with the written consent of
the Company

 

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and the holders of Warrants issued under the Subscription Agreements
representing two-thirds of the Warrant Shares issuable under Warrants then
outstanding as of the date such consent is sought; provided, however, that (i) no such amendment shall
adversely affect any Holder differently than it affects all other Holders,
unless such Holder consents thereto and (ii) no amendment may increase
the Exercise Price, decrease the number of shares or class of shares
obtainable upon exercise of this Warrant or decrease the time period in which
this Warrant can be exercised without the written consent of the Holder.

 

(h)                                 Severability. Wherever possible, each provision of this
Warrant shall be interpreted in such manner as to be effective and valid under
applicable law, but if any provision of this Warrant shall be prohibited by or
invalid under applicable law, such provision shall be ineffective to the extent
of such prohibition or invalidity, without invalidating the remainder of such
provisions or the remaining provisions of this Warrant.

 

(i)                                     Headings. The headings used in this Warrant are for the convenience of
reference only and shall not, for any purpose, be deemed a part of this
Warrant.

 

(j)                                     Acceptance. Receipt of this Warrant by the Holder shall constitute acceptance of
and agreement to all of the terms and conditions contained herein.

 

8

 

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

 

Dated: April    ,
2006

 

	
   

  	
  ACUSPHERE, INC.

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
  Name:

  
	
   

  	
  Title:

  

 

 

NOTICE OF EXERCISE

 

To: Acusphere, Inc.

 

(1)                                  The undersigned hereby elects to purchase                 
Warrant Shares of Acusphere, Inc. pursuant to the terms of the attached
Warrant, and tenders herewith payment of the exercise price of such Warrant
Shares in full, together with all applicable transfer taxes, if any.

 

(2)                                  Payment shall take the form of lawful
money of the United States.

 

(3)                                  Please issue a certificate or certificates
representing said Warrant Shares in the name of the undersigned or in such
other name as is specified below:

 

The Warrant Shares shall be
delivered to the following:

 

 

 

 

OR

 

DWAC the shares to:

 

	
   

  	
  DTC#

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Account #

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Reference#

  	
   

  	
   

  

 

SIGNATURE OF HOLDER

 

	
   

  	
  Dated as of:

  	
   

  	
   

  	
   

  	
  ,

  	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  HOLDER

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  	
   

  
	
   

  	
  Print Name:

  	
   

  	
   

  
												

 

 

ASSIGNMENT FORM

 

for

 

Common Stock Purchase Warrant

of Acusphere, Inc.

 

(To assign the foregoing Warrant, execute

this form and supply required information. 

Do not use this form to exercise the warrant.)

 

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

 

                                                                                                                                                       
whose address is

 

 

 

	
   

  	
   

  	
  Dated:

  	
   

  
	
   

  	
   

  	
   

  
	
  Holder’s Signature:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Holder’s Address:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature Guaranteed:

  	
   

  	
   

  	
   

  
								

 

NOTE:
The signature to this Assignment Form must correspond with the name as it
appears on the face of the Warrant, without alteration or enlargement or any
change whatsoever, and must be guaranteed by a bank or trust company. Officers
of corporations and those acting in a fiduciary or other representative
capacity should file proper evidence of authority to assign the foregoing
Warrant.Exhibit
10.1

 

SUBSCRIPTION
AGREEMENT

 

Acusphere, Inc.

500 Arsenal Street

Watertown, MA 02472

 

Ladies and Gentlemen:

 

The undersigned (the “Investor”) hereby confirms its agreement
with you as follows:

 

1.             This Subscription Agreement (this “Agreement”) is made as of the date set
forth below between Acusphere, Inc., a Delaware corporation (the “Company”), and the Investor.

 

2.             The Company has authorized the sale and
issuance to certain investors of up to an aggregate of 5,772,004 units (the “Units”),
each consisting of (i) one share (the “Share,”
collectively the “Shares”) of its
Common Stock, par value $0.01 per share (the “Common
Stock”) and (ii) one warrant (the “Warrant,”
collectively the “Warrants”) to
purchase 0.3 Shares of Common
Stock (and the fraction amount being the “Warrant
Ratio”), in substantially the form attached hereto as Exhibit A,
subject to adjustment by the Company’s Board of Directors, or a committee
thereof, for a purchase price of $6.9675
per Unit (the “Purchase Price”),
reflecting a price of $6.93 per Share and $0.0375 per Warrant.  The Shares issuable upon the exercise of the
Warrants are referred to herein as the “Warrant
Shares” and, together with the Units, the Shares and the Warrants,
are referred to herein as the “Securities.”

 

3.             The offering and sale of the Units (the “Offering”) are being made pursuant to (1)
an effective Registration Statement on Form S-3 (including the Prospectus
contained therein (the “Base Prospectus”),
the “Registration Statement”)
filed by the Company with the Securities and Exchange Commission (the “Commission”), (2) if applicable, certain
“free writing prospectuses” (as that term is defined in Rule 405 under the
Securities Act of 1933, as amended), that have or will be filed with the
Commission and delivered to the Investor on or prior to the date hereof and (3)
a Prospectus Supplement (the “Prospectus
Supplement” and together with the Base Prospectus, the “Prospectus”) containing certain
supplemental information regarding the Securities and terms of the Offering
that will be filed with the Commission and delivered to the Investor along with
the Company’s counterpart to this Agreement.

 

4.             The Company and the Investor agree that the
Investor will purchase from the Company and the Company will issue and sell to
the Investor the Units set forth below for the aggregate purchase price set
forth below.  The Units shall be
purchased pursuant to the Terms and Conditions for Purchase of Units attached
hereto as Annex I and incorporated herein by this reference as if fully
set forth herein.  The Investor
acknowledges that the Offering is not being underwritten by the placement agent
(the “Placement Agent”) named in
the Prospectus Supplement and that there is no minimum offering amount.

 

5.             The manner of settlement of the Shares
included in the Units purchased by the Investor shall be determined by such
Investor as follows (check one):

 

o             A.    Delivery by electronic book-entry at The
Depository Trust Company (“DTC”),
registered in the Investor’s name and address as set forth below, and released
by American Stock Transfer & Trust Company, the Company’s transfer agent
(the “Transfer Agent”), to the
Investor at the Closing.  NO LATER THAN ONE (1) BUSINESS DAY AFTER THE EXECUTION
OF THIS AGREEMENT BY THE INVESTOR AND THE COMPANY, THE INVESTOR SHALL:

 

(I)    DIRECT THE BROKER-DEALER AT
WHICH THE ACCOUNT OR ACCOUNTS TO BE CREDITED WITH THE SHARES ARE MAINTAINED TO
SET UP A

 

 

DEPOSIT/WITHDRAWAL
AT CUSTODIAN (“DWAC”) INSTRUCTING
THE TRANSFER AGENT TO CREDIT SUCH ACCOUNT OR ACCOUNTS WITH THE SHARES, AND

 

(II)   REMIT BY WIRE TRANSFER THE
AMOUNT OF FUNDS EQUAL TO THE AGGREGATE PURCHASE PRICE FOR THE UNITS BEING
PURCHASED BY THE INVESTOR TO THE FOLLOWING ACCOUNT:

 

THE CITIBANK PRIVATE BANK

666 Fifth Avenue, 5th Floor

New York, NY 10103

ABA # 021-000-089

Account Name: Acusphere, Inc.

Account Number: 76-274024

 

– OR –

 

o             B.    Delivery versus payment (“DVP”) through DTC (i.e., the Company shall
deliver Shares registered in the Investor’s name and address as set forth below
and released by the Transfer Agent to the Investor at the Closing directly to
the account(s) at Cowen & Co., LLC identified by the Investor and
simultaneously therewith payment shall be made from such account(s) to the
Company through DTC).  NO LATER THAN ONE (1) BUSINESS DAY AFTER THE EXECUTION
OF THIS AGREEMENT BY THE INVESTOR AND THE COMPANY, THE INVESTOR SHALL:

 

(I)    NOTIFY COWEN & CO., LLC
OF THE ACCOUNT OR ACCOUNTS AT COWEN & CO., LLC TO BE CREDITED WITH THE
SHARES BEING PURCHASED BY SUCH INVESTOR, AND

 

(II)   CONFIRM THAT THE ACCOUNT OR
ACCOUNTS AT COWEN & CO., LLC TO BE CREDITED WITH THE SHARES BEING PURCHASED
BY THE INVESTOR HAVE A MINIMUM BALANCE EQUAL TO THE AGGREGATE PURCHASE PRICE
FOR THE UNITS BEING PURCHASED BY THE INVESTOR.

 

IT IS THE
INVESTOR’S RESPONSIBILITY TO (A) MAKE THE NECESSARY WIRE TRANSFER OR CONFIRM
THE PROPER ACCOUNT BALANCE IN A TIMELY MANNER AND (B) ARRANGE FOR SETTLEMENT BY
WAY OF DWAC OR DVP IN A TIMELY MANNER. 
IF THE INVESTOR DOES NOT DELIVER THE AGGREGATE PURCHASE PRICE FOR THE
UNITS OR DOES NOT MAKE PROPER ARRANGEMENTS FOR SETTLEMENT IN A TIMELY MANNER,
THE SHARES AND WARRANTS MAY NOT BE DELIVERED AT CLOSING TO THE INVESTOR OR THE
INVESTOR MAY BE EXCLUDED FROM THE CLOSING ALTOGETHER.

 

6.             The executed Warrant shall be delivered in
accordance with the terms thereof.

 

7.             The
Investor represents that, except as set forth below, (a) it has had no
position, office or other material relationship within the past three years
with the Company or persons known to it to be affiliates of the Company, (b) it
is not a NASD member or an Associated Person (as such term is defined under the
NASD Membership and Registration Rules Section 1011) as of the Closing, and (c)
neither the Investor nor any group of Investors (as identified in a public
filing made with the Commission) of which the Investor is a part in connection
with the Offering of the Units, acquired, or obtained the right to acquire, 20%
or more of the Common Stock (or securities convertible into or exercisable for
Common Stock) or the voting power of the Company on a post-transaction
basis.  Exceptions:

 

2

 

(If
no exceptions, write “none.” If left blank, response will be deemed to be
“none.”)

 

8.             The Investor represents that it has received
the final Base Prospectus, dated April 5, 2005, which is a part of the
Company’s Registration Statement, and any free writing prospectus, prior to or
in connection with the receipt of this Agreement (collectively, the “Disclosure Package”) and the Prospectus
Supplement along with the Company’s counterpart to this Agreement .

 

9.             No
offer by the Investor to buy Units will be accepted and no part of the Purchase
Price will be delivered to the Company until the Company has accepted such
offer by countersigning a copy of this Agreement, and any such offer may be
withdrawn or revoked, without obligation or commitment of any kind, at any time
prior to the Company (or a Placement Agent on behalf of the Company) sending
(orally, in writing, or by electronic mail) notice of its acceptance of such
offer.  An indication of interest will
involve no obligation or commitment of any kind until this Agreement is
accepted and countersigned by or on behalf of the Company.

 

3

 

Number
of Units:           

Purchase Price Per Unit: $     

Aggregate Purchase Price: $    

 

Please confirm that the
foregoing correctly sets forth the agreement between us by signing in the space
provided below for that purpose.

 

 

	
   

  	
  Dated as of:  April    , 2006

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  INVESTOR

  	
   

  
	
   

  	
  By:

  	
   

  	
   

  
	
   

  	
  Print Name:

  	
   

  	
   

  
	
   

  	
  Title:

  	
   

  	
   

  
	
   

  	
  Address:

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
							

 

Agreed and Accepted

this     
day of April, 2006:

 

ACUSPHERE, INC.

 

	
  By:

  	
   

  	
   

  
	
  Title:

  

 

4

 

ANNEX I

 

TERMS AND CONDITIONS FOR PURCHASE OF UNITS

 

1.             Authorization and Sale of
the Units.  Subject to the terms and conditions of this
Agreement, the Company has authorized the sale of the Units, which consist of
the Shares and the Warrants.

 

2.             Agreement to Sell and Purchase the Units; Placement
Agent.

 

2.1          At the Closing (as defined in Section 3.1),
the Company will sell to the Investor, and the Investor will purchase from the
Company, upon the terms and conditions set forth herein, the number of Units
set forth on the last page of the Agreement to which these Terms and Conditions
for Purchase of Units are attached as Annex I (the “Signature Page”) for the aggregate
purchase price therefor set forth on the Signature Page.

 

2.2          The Company proposes to enter into
substantially this same form of Subscription Agreement with certain other
investors (the “Other Investors”)
and expects to complete sales of Units to them. 
The Investor and the Other Investors are hereinafter sometimes
collectively referred to as the “Investors,”
and this Agreement and the Subscription Agreements executed by the Other
Investors are hereinafter sometimes collectively referred to as the “Agreements.”

 

2.3          Investor acknowledges that the Company
intends to pay Cowen & Co., LLC (the “Placement
Agent”) a fee (the “Placement Fee”)
in respect of the sale of Units to the Investor.

 

2.4          The Company has entered into a Placement
Agent Agreement, dated April [     ],
2006 (the “Placement Agreement”)
with the Placement Agent that contains certain representations, warranties,
covenants, agreements and indemnities of the Company that may be relied upon by
the Investor, which shall be a third party beneficiary thereof.  A copy of the Placement Agreement is
available upon request.

 

3.             Closings and Delivery of the Units and Funds.

 

3.1          Closing.  The completion of the purchase and sale of
the Units (the “Closing”) shall
occur at a place and time (the “Closing Date”)
to be specified by the Company and the Placement Agent, and of which the
Investors will be notified in advance by the Placement Agent, in accordance
with Rule 15c6-1 promulgated under the Securities Exchange Act of 1934, as
amended (the “Exchange Act”).  At the Closing, (a) the Company shall cause
the Transfer Agent to deliver to the Investor the number of Shares (and Units)
set forth on the Signature Page registered in the name of the Investor or, if
so indicated on the Investor Questionnaire attached hereto as Exhibit A,
in the name of a nominee designated by the Investor, (b) the Company shall
cause to be delivered to the Investor a Warrant to purchase a number of whole
Warrant Shares determined by multiplying the number of Shares (and Units) set
forth on the signature page by the Warrant Ratio and rounding down to the
nearest whole number, and (c) the aggregate purchase price for the Units being
purchased by the Investor will be delivered by or on behalf of the Investor to
the Company.

 

3.2          (a)           Conditions to the Company’s
Obligations.  The Company’s obligation to issue and sell
the Units to the Investor shall be subject to: (a) the receipt by the Company
of the purchase price for the Units being purchased hereunder as set forth on
the Signature Page and (b) the accuracy of the representations and warranties
made by the Investor and the fulfillment of those undertakings of the Investor
to be fulfilled prior to the Closing Date.

 

(b)           Conditions to the Investor’s
Obligations.  The Investor’s obligation to purchase the
Units will be subject to the accuracy of the representations and warranties
made by the Company and the fulfillment of those undertakings of the Company to
be fulfilled prior to the Closing Date, including without limitation, those
contained in the Placement Agreement, and to the condition that the Placement
Agent

 

5

 

shall not have: (a) terminated
the Placement Agreement pursuant to the terms thereof or (b) determined that
the conditions to the closing in the Placement Agreement have not been
satisfied.  The Investor’s obligations
are expressly not conditioned on the purchase by any or all of the Other
Investors of the Units that they have agreed to purchase from the Company.

 

3.3          Delivery of Funds.

 

(a)           Delivery by Electronic Book-Entry at The
Depository Trust Company.  If the Investor elects to settle the Shares
purchased by such Investor through delivery by electronic book-entry at DTC, no later than one (1) business day after the execution
of this Agreement by the Investor and the Company, the Investor
shall remit by wire transfer the amount of funds equal to the aggregate
purchase price for the Units being purchased by the Investor to the following
account designated by the Company and the Placement Agent pursuant to the terms
of that certain Escrow Agreement (the “Escrow
Agreement”) dated as of April [     ],
2006, by and among the Company, the Placement Agent and Brown Raysman Millstein
Felder & Steiner LLP (the “Escrow Agent”):

 

THE CITIBANK PRIVATE BANK

666 Fifth Avenue, 5th Floor

New York, NY 10103

ABA # 021-000-089

Account Name: Acusphere, Inc.

Account Number: 76-274024

 

Such funds shall be held in
escrow until the Closing and delivered by the Escrow Agent on behalf of the
Investors to the Company upon the satisfaction, in the sole judgment of the
Placement Agent, of the conditions set forth in Section 3.2(b) hereof.  The Placement Agent shall have no rights in
or to any of the escrowed funds, unless the Placement Agent and the Escrow
Agent are notified in writing by the Company in connection with the Closing
that a portion of the escrowed funds shall be applied to the Placement Fee.  The Company and the Investor agree to
indemnify and hold the Escrow Agent harmless from and against any and all
losses, costs, damages, expenses and claims (including, without limitation,
court costs and reasonable attorneys fees) (“Losses”)
arising under this Section 3.3 or otherwise with respect to the funds
held in escrow pursuant hereto or arising under the Escrow Agreement, unless it
is finally determined that such Losses resulted directly from the willful
misconduct or gross negligence of the Escrow Agent.  Anything in this Agreement to the contrary
notwithstanding, in no event shall the Escrow Agent be liable for any special,
indirect or consequential loss or damage of any kind whatsoever (including but
not limited to lost profits), even if the Escrow Agent has been advised of the
likelihood of such loss or damage and regardless of the form of action.

 

Investor shall also furnish
to the Placement Agent a completed W-9 form (or, in the case of an Investor who
is not a United States citizen or resident, a W-8 form).

 

Investor acknowledges that
the Escrow Agent acts as counsel to the Placement Agent, and shall have the
right to continue to represent the Placement Agent, in any action, proceeding,
claim, litigation, dispute, arbitration or negotiation in connection with the
Offering, and Investor hereby consents thereto and waives any objection to the
continued representation of the Placement Agent by the Escrow Agent in
connection therewith based upon the services of the Escrow Agent under the
Escrow Agreement, without waiving any duty or obligation the Escrow Agent may
have to any other person.

 

(b)           Delivery Versus Payment through The
Depository Trust Company.  If the Investor elects to settle the Shares
purchased by such Investor by delivery versus payment through DTC, no later than one (1) business day after the execution
of this Agreement by the Investor and the Company, the Investor
shall confirm that the account or accounts at Cowen & Co., LLC to be
credited with the Shares

 

6

 

being purchased by the Investor
have a minimum balance equal to the aggregate purchase price for the Units
being purchased by the Investor.

 

3.4          Delivery of Shares.

 

(a)           Delivery by Electronic Book-Entry at The
Depository Trust Company.  If the Investor elects to settle the Shares
purchased by such Investor through delivery by electronic book-entry at DTC, no later than one (1) business day after the execution
of this Agreement by the Investor and the Company, the Investor
shall direct the broker-dealer at which the account or accounts to be credited
with the Shares being purchased by such Investor are maintained, which
broker/dealer shall be a DTC participant, to set up a Deposit/Withdrawal at
Custodian (“DWAC”) instructing American Stock Transfer & Trust Company, the
Company’s transfer agent, to credit such account or accounts with the Shares by
means of an electronic book-entry delivery. 
Such DWAC shall indicate the settlement date for the deposit of the
Shares, which date shall be provided to the Investor by the Placement
Agent.  Simultaneously with the delivery
to the Company by the Escrow Agent of the funds held in escrow pursuant to Section
3.3 above, the Company shall direct its transfer agent to credit the
Investor’s account or accounts with the Shares pursuant to the information
contained in the DWAC.

 

(b)           Delivery Versus Payment through The
Depository Trust Company.  If the Investor elects to settle the Shares
purchased by such Investor by delivery versus payment through DTC, no later than one (1) business day after the execution
of this Agreement by the Investor and the Company, the Investor
shall notify Cowen & Co., LLC of the account or accounts at Cowen &
Co., LLC to be credited with the Shares being purchased by such Investor.  On the Closing Date, the Company shall
deliver the Shares to the Investor directly to the account(s) at Cowen &
Co., LLC identified by Investor and simultaneously therewith payment shall be
made from such account(s) to the Company through DTC.

 

4.             Representations, Warranties and Covenants of the
Investor.

 

4.1          The
Investor represents and warrants to, and covenants with, the Company that (a)
the Investor is knowledgeable, sophisticated and experienced in making, and is
qualified to make decisions with respect to, investments in shares presenting
an investment decision like that involved in the purchase of the Units,
including investments in securities issued by the Company and investments in
comparable companies, and has requested, received, reviewed and considered all
information it deemed relevant in making an informed decision to purchase the
Units, (b) the Investor has answered all questions on the Signature Page and
the Investor Questionnaire for use in preparation of the Prospectus Supplement and
the answers thereto are true and correct as of the date hereof and will be true
and correct as of the Closing Date and (c) the Investor, in connection with its
decision to purchase the number of Units set forth on the Signature Page, is
relying only upon the Disclosure Package, the documents incorporated by
reference therein and the representations and warranties of the Company
contained herein.

 

4.2          The Investor acknowledges, represents and
agrees that no action has been or will be taken in any jurisdiction outside the
United States by the Company or any Placement Agent that would permit an
offering of the Units, or possession or distribution of offering materials in
connection with the issue of the Securities in any jurisdiction outside the
United States where action for that purpose is required.  Each Investor outside the United States will
comply with all applicable laws and regulations in each foreign jurisdiction in
which it purchases, offers, sells or delivers the Securities or has in its
possession or distributes any offering material, in all cases at its own
expense.  The Placement Agent is not
authorized to make and has not made any representation or use of any
information in connection with the issue, placement, purchase and sale of the
Units, except as set forth or incorporated by reference in the Base Prospectus
or the Prospectus Supplement.

 

4.3          The
Investor further represents and warrants to, and covenants with, the Company
that (a) the Investor has full right, power, authority and capacity to enter
into this Agreement and to consummate the transactions contemplated hereby and
has taken all necessary action to authorize the execution, delivery and

 

7

 

performance of this Agreement,
and (b) this Agreement constitutes a valid and binding obligation of the
Investor enforceable against the Investor in accordance with its terms, except
as enforceability may be limited by applicable bankruptcy, insolvency,
reorganization, moratorium or similar laws affecting creditors’ and contracting
parties’ rights generally and except as enforceability may be subject to
general principles of equity (regardless of whether such enforceability is
considered in a proceeding in equity or at law) and except as the indemnification
agreements of the Investors herein may be legally unenforceable.

 

4.4          The Investor understands that nothing in this
Agreement, the Prospectus or any other materials presented to the Investor in
connection with the purchase and sale of the Units constitutes legal, tax or
investment advice.  The Investor has
consulted such legal, tax and investment advisors as it, in its sole
discretion, has deemed necessary or appropriate in connection with its purchase
of Units.

 

4.5          Each Investor represents, warrants and agrees
that, since the date on which the Placement Agent first contacted such Investor
about the Offering, it has not engaged in any transactions in the securities of
the Company (including, without limitation, any Short Sales involving the
Company’s securities).  Each Investor
covenants that it will not engage in any transactions in the securities of the
Company (including Short Sales), except for transactions entered into on behalf
of the Investor by third-party managers exercising investment discretion on
behalf of the Investor, prior to the time that the transactions contemplated by
this Agreement are publicly disclosed. 
Each Investor agrees that it will not use any of the Units acquired
pursuant to this Agreement to cover any short position in the Common Stock if
doing so would be in violation of applicable securities laws.  For purposes hereof, “Short Sales” include,
without limitation, all “short sales” as defined in Rule 200 promulgated under
Regulation SHO under the Exchange Act, whether or not against the box, and all
types of direct and indirect stock pledges, forward sales contracts, options,
puts, calls, short sales, swaps, “put equivalent positions” (as defined in Rule
16a-1(h) under the Exchange Act) and similar arrangements (including on a total
return basis), and sales and other transactions through non-US broker dealers
or foreign regulated brokers.

 

5.             Survival of Representations, Warranties and
Agreements.  Notwithstanding any investigation made by any
party to this Agreement or by the Placement Agent, all covenants, agreements,
representations and warranties made by the Company and the Investor herein will
survive the execution of this Agreement, the delivery to the Investor of the
Units being purchased and the payment therefor.

 

6.             Notices.  All notices, requests, consents and other
communications hereunder will be in writing, will be mailed (a) if within the
domestic United States by first-class registered or certified airmail, or
nationally recognized overnight express courier, postage prepaid, or by
facsimile or (b) if delivered from outside the United States, by International
Federal Express or facsimile, and will be deemed given (i) if delivered by
first-class registered or certified mail domestic, three business days after so
mailed, (ii) if delivered by nationally recognized overnight carrier, one
business day after so mailed, (iii) if delivered by International Federal
Express, two business days after so mailed and (iv) if delivered by facsimile,
upon electric confirmation of receipt and will be delivered and addressed as
follows:

 

(a)           if to the Company, to:

 

Acusphere,
Inc.

500
Arsenal Street

Watertown,
MA 02472

Attention:
John F. Thero

Facsimile:
(617) 926-3605

 

8

 

with
copies to:

 

Goodwin
Procter, LLP

53
State Street

Boston,
MA 02109

Attention:
Lawrence S. Wittenberg, Esq.

Facsimile: (617) 523-1231

 

(b)           if to the Investor, at its address on the
Signature Page hereto, or at such other address or addresses as may have been
furnished to the Company in writing.

 

7.             Changes.  This Agreement may not be modified or amended
except pursuant to an instrument in writing signed by the Company and the
Investor.

 

8.             Headings.  The headings of the various sections of this
Agreement have been inserted for convenience of reference only and will not be
deemed to be part of this Agreement.

 

9.             Severability.  In case any provision contained in this
Agreement should be invalid, illegal or unenforceable in any respect, the
validity, legality and enforceability of the remaining provisions contained
herein will not in any way be affected or impaired thereby.

 

10.          Governing Law.  This Agreement will be governed by, and
construed in accordance with, the internal laws of the State of New York,
without giving effect to the principles of conflicts of law that would require
the application of the laws of any other jurisdiction.

 

11.          Counterparts.  This Agreement may be executed in two or more
counterparts, each of which will constitute an original, but all of which, when
taken together, will constitute but one instrument, and will become effective
when one or more counterparts have been signed by each party hereto and
delivered to the other parties.  The
Company and the Investor acknowledge and agree that the Company shall deliver
its counterpart to the Investor along with the Prospectus Supplement.

 

12.          Confirmation of Sale.  The Investor acknowledges and
agrees that such Investor’s receipt of the Company’s counterpart to this
Agreement, together with the Prospectus Supplement, shall constitute written
confirmation of the Company’s sale of Units to such Investor.

 

13.          Press Release.  The Company and the Investor
agree that the Company shall issue a press release announcing the Offering
prior to the opening of the financial markets in New York City on the business
day immediately after the date hereof.

 

14.          Termination.  In the event that the Placement Agreement is
terminated by the Placement Agent pursuant to the terms thereof, this Agreement
shall terminate without any further action on the part of the parties hereto.

 

9

 

EXHIBIT A

 

ACUSPHERE, INC.

 

INVESTOR QUESTIONNAIRE

 

Pursuant to Section 3
of Annex I to the Agreement, please provide us with the following
information:

 

	
  1.

  	
  The exact name that your
  Shares and Warrants are to be registered in. You may use a nominee name if
  appropriate:

  	
   

  
	
   

  	
   

  	
   

  
	
  2.

  	
  The relationship between
  the Investor and the registered holder listed in response to item 1 above:

  	
   

  
	
   

  	
   

  	
   

  
	
  3.

  	
  The mailing address of the
  registered holder listed in response to item 1 above:

  	
   

  
	
   

  	
   

  	
   

  
	
  4.

  	
  The Social Security Number
  or Tax Identification Number of the registered holder listed in the response
  to item 1 above:

  	
   

  
	
   

  	
   

  	
   

  
	
  5.

  	
  Name of DTC Participant
  (broker-dealer at which the account or accounts to be credited with the
  Shares are maintained):

  	
   

  
	
   

  	
   

  	
   

  
	
  6.

  	
  DTC Participant Number:

  	
   

  
	
   

  	
   

  	
   

  
	
  7.

  	
  Name of Account at DTC
  Participant being credited with the Shares:

  	
   

  
	
   

  	
   

  	
   

  
	
  8.

  	
  Account Number at DTC
  Participant being credited with the Shares:

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