Document:

EX-4.3

 Exhibit 4.3 
  

			
	RIGHTS CERTIFICATE #:                         	  	                         NUMBER OF RIGHTS

 THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE LGL GROUP, INC.’S PROSPECTUS DATED
[    ], 2017 (THE “PROSPECTUS”) AND ARE INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM BROADRIDGE CORPORATE ISSUER SOLUTIONS INC., THE INFORMATION AGENT, BY
TELEPHONE ((855) 793-5068) OR EMAIL (SHAREHOLDER@BROADRIDGE.COM). 
 The LGL Group, Inc. 

Incorporated under the laws of the State of Delaware 

TRANSFERABLE SUBSCRIPTION RIGHTS CERTIFICATE 

Evidencing Transferable Subscription Rights to Purchase Shares of Common Stock of The LGL Group, Inc. 

Subscription Price: $5.50 per whole share of Common Stock 

THE SUBSCRIPTION RIGHTS WILL EXPIRE IF NOT EXERCISED ON OR BEFORE 

5:00 P.M., EASTERN TIME, ON OCTOBER 10, 2017, UNLESS EXTENDED BY THE COMPANY 

REGISTERED OWNER:
                                         
                                         
               
 THIS CERTIFIES THAT the registered owner whose name is inscribed
hereon is the owner of the number of transferable subscription rights (“Rights”) set forth above. Each Right entitles the holder thereof to subscribe for and purchase one-fourth of a share of common stock, par value
$0.01 per share (the “Common Stock”), of The LGL Group, Inc., a Delaware corporation, at a subscription price (the “Subscription Price”) of $5.50 per whole share of Common Stock (the “Basic
Subscription Right”), pursuant to a rights offering (the “Rights Offering”), on the terms and subject to the conditions set forth in the Prospectus and the “Instructions for Use of The LGL Group, Inc.
Subscription Rights Certificate” accompanying this Subscription Rights Certificate. If any shares of Common Stock available for purchase in the Rights Offering are not purchased by other holders of Rights pursuant to the exercise of their Basic
Subscription Right (the “Over-Subscription Shares”), any Rights holder that exercises its Basic Subscription Right in full (other than those subscription rights to acquire less than one whole share of Common Stock, which
cannot be exercised) may purchase a number of Over-Subscription Shares (the “Over-Subscription Right”) pursuant to the terms and conditions of the Rights Offering, as described in the Prospectus. The Rights represented by
this Subscription Rights Certificate may be exercised by completing Form 1 and any other appropriate forms on the reverse side hereof and by returning the full payment of the subscription price for each share of Common Stock in accordance with
the “Instructions for Use of The LGL Group, Inc. Subscription Rights Certificate” that accompany this Subscription Rights Certificate. 
 The
undersigned acknowledges that the number of shares that the undersigned may obtain by subscribing for shares in the Rights Offering cannot be determined until the expiration of the offering period, as described in the Prospectus. 

This Subscription Rights Certificate is not valid unless countersigned by Broadridge Corporate Issuer Solutions Inc., as the subscription agent, and
registered by the registrar. 
 Witness the signatures of the duly authorized officers of The LGL Group, Inc. 

 

			
	Dated:	 	  

  

							
	  
 President and Chief
Executive Officer
	 		  	  
 Secretary
	  	

 DELIVERY OPTIONS FOR SUBSCRIPTION RIGHTS CERTIFICATE 

Delivery other than in the manner or to the address listed below will not constitute valid delivery. 

 

			
	By mail:	  	 By hand delivery or overnight courier,

excluding U.S. Postal Service:

		
	 Broadridge Corporate Issuer Solutions Inc.

Attn: BCIS Re-Organization Dept.
 P.O. Box 1317

Brentwood, NY 11717-0693
 (855) 793-5068 (toll free)
	  	 Broadridge Corporate Issuer Solutions Inc.

Attn: BCIS IWS
 51 Mercedes Way

Edgewood, NY 11717
 (855) 793-5068 (toll free)

 PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY. 

 
  

FORM 1-EXERCISE OF SUBSCRIPTION RIGHTS 
 To invest and
purchase shares pursuant to your Basic Subscription Right, please complete lines (a) and (c) and sign under Form 3 below. To invest and purchase shares pursuant to your Over-Subscription Right, please also complete line (b) and sign under Form 3
below. To the extent your investment exceeds Shares that you are entitled under either the Basic Subscription Right or the Over-Subscription Right, you will be deemed to have elected to purchase the maximum number of shares for which you are
entitled to under the Basic Subscription Right or Over-Subscription Right, as applicable. 
 (a) EXERCISE OF BASIC SUBSCRIPTION RIGHT 

 

															
		 	  
 I apply for:
	 	                   shares	 	x	 	$5.50	 	=	 	$                  	 	
		 		 	(no. of new shares	 		 	(Subscription	 		 	(amount	 	
		 		 	of Common Stock)	 		 	Price)	 		 	enclosed)	 	

 (b) EXERCISE OF OVER-SUBSCRIPTION RIGHT 

If you have exercised your Basic Subscription Right in full and wish to purchase additional shares of Common Stock pursuant to your Over-Subscription Right:

  

															
		 	 I apply for:
	 	                   shares	 	x	 	$5.50	 	=	 	$                  	 	
		 		 	(no. of new shares	 		 	(Subscription	 		 	(amount	 	
		 		 	of Common Stock)	 		 	Price)	 		 	enclosed)	 	

 (c) Total Amount of Payment Enclosed =
$                   
 METHOD OF PAYMENT (CHECK ONE) 

☐     Check or bank draft payable to “Broadridge Corporate Issuer Solutions, Inc., as
Subscription Agent for The LGL Group, Inc.” 
 ☐     Wire transfer of immediately available
funds directly to the account maintained by Broadridge Corporate Issuer Solutions, Inc., as Subscription Agent, for purposes of accepting subscriptions in this Rights Offering to Wells Fargo (420 Montgomery Street, San Francisco, CA 94104), for
credit to for Broadridge Corporate Issuer Solutions, Inc., ABA No. 121000248, further credit to Account Number 4124218686, with reference to the Rights holder’s name. 

 
  

FORM 2-DELIVERY TO DIFFERENT ADDRESS 
 If you wish for the
Common Stock underlying your Rights, or a certificate representing unexercised Rights to be delivered to an address different from that shown on the face of this Subscription Rights Certificate, please enter the alternate address below, sign under
Form 3 and have your signature guaranteed under Form 4. 
  

			
	 	 	 
	 	 	 
	Address (if different than address listed on Subscription Rights Certificate)
	 	 	 
	Telephone number (including area code)

  

 
 FORM 3-SIGNATURE 

TO SUBSCRIBE: I acknowledge that I have received the Prospectus for the rights offering and I hereby irrevocably invest the amount indicated under Form 1 above
on the terms and conditions specified in the Prospectus. This Form 3 must be signed by the registered holder(s) exactly as their name(s) appear(s) on the certificate(s) or by person(s) authorized to sign on behalf of the registered holder(s) by
documents transmitted herewith. 
 Signature of Registered Holder:
                                         
                
 Date:
                                         
        
 If signature is by a trustee(s), executor(s), administrator(s), attorney(s)-in-fact, officer(s) of a
corporation or another acting in a fiduciary or representative capacity, please provide the following information (please print). 
 Name:
                                         
                                         
   
 Capacity:
                                         
                                        

Soc. Sec. #/Tax ID#:
                                         
                    
 Address:
                                         
                                        

Phone:
                                         
                                         
   
  
  

FORM 4-SIGNATURE GUARANTEE 
 This form must be completed
if you have completed any portion of Form 2. 

			
		 	
	Signature Guaranteed:	 	
                          
                                  

		 	(Name of Bank or Firm)

			
		
	By:	 	                                     
                       
		 	(Signature of Officer)                    
		
		 	                                     
                       
		 	(Print Name of Officer)                    

IMPORTANT: The signature(s) should be guaranteed by an eligible guarantor institution (bank, stock broker, savings & loan association or credit union)
with membership in an approved signature guarantee medallion program pursuant to Securities and Exchange Commission Rule 17Ad-15. 
 FOR INSTRUCTIONS ON THE
USE OF THE LGL GROUP, INC. SUBSCRIPTION RIGHTS CERTIFICATE, CONSULT BROADRIDGE CORPORATE ISSUER SOLUTIONS INC., THE INFORMATION AGENT, BY TELEPHONE ((855) 793-5068) OR EMAIL (SHAREHOLDER@BROADRIDGE.COM).FORM
OF

 

RENNOVA
HEALTH, INC.

 

2007
INCENTIVE AWARD PLAN

 

GRANT
AGREEMENT

 

THIS
GRANT AGREEMENT (this “Agreement”), is made and effective as of this 15th day of August, 2017 (the “Grant
Date”), by and between Rennova Health, Inc., a Delaware corporation (“Rennova”), and  _________ (the “Participant”).

 

W
I T N E S S E T H:

 

WHEREAS,
Rennova is desirous of increasing the incentive of the Participant whose contributions are important to the continued success
of Rennova;

 

NOW,
THEREFORE, in consideration of the foregoing, and for other good and valuable consideration, Rennova hereby grants the Participant
an award pursuant to the Rennova Health, Inc. 2007 Incentive Award Plan (the “Plan”) subject to the terms and conditions
below. Capitalized terms not defined herein shall have the meaning ascribed thereto in the Plan.

 

1.
GRANT OF RESTRICTED STOCK

 

Pursuant
to the provisions of the Plan, the Committee hereby awards to the Participant _________ shares of common stock subject to the terms
and conditions of the Plan and the terms and conditions set forth herein.

 

2.
VESTING

 

Subject
to Section 4 hereof, 100% of the common stock shall vest on the first anniversary of the Grant Date (the “Vesting Date”),
subject to the participant’s continued status as _________ on the vesting date. There shall be no proportionate or partial
vesting in the period between Grant Date and the Vesting Date.

 

3.
TRANSFER AND SHAREHOLDER RIGHTS

 

(
a ) Transfer. Participant shall not sell, negotiate, transfer, pledge, hypothecate, assign or otherwise dispose of the common
stock until after the vesting date.

 

(
b ) Shareholder Rights. Until the expiration of the applicable restricted period, (i) the common stock shall be treated as outstanding,
(ii) unless otherwise provided in the Plan or herein, the Participant holding shares of common stock may exercise full rights
with respect to such shares, and (iii) the Participant holding shares of common stock shall be entitled to receive all dividends
and other distributions paid with respect to such shares while they are so held. In the discretion of the Committee, dividends
or other distributions with respect to common stock may be (a) subject to the same restrictions on transferability and forfeitability
as the shares of common stock with respect to which they were paid, and (b) placed in escrow until the expiration of applicable
restrictions.

 

    	 	 	 

     

    

 

4.
TERMINATION OF EMPLOYMENT

 

Upon
the Participant’s termination of employment and other service with the Company for any reason, the unvested portion of the
common stock as of the time of such termination shall be immediately forfeited to Rennova and the Participant shall have no rights
whatsoever with respect to such forfeited common stock.

 

5.
MISCELLANEOUS

 

(
a ) Controlling Law. This Agreement and all questions relating to its validity, interpretation, performance, and enforcement (including,
without limitation, provisions concerning limitations of actions), shall be governed by, and construed in accordance with the
laws of the State of Delaware, without application to the principles of conflict of laws.

 

(
b ) Provisions of Plan Control. This Agreement is subject to all the terms, conditions and provisions of the Plan, including,
without limitation, the amendment provisions thereof, and to such rules, regulations and interpretations relating to the Plan
as may be adopted by the Committee and as may be in effect from time to time. The Plan is incorporated herein by reference. If
and to the extent that this Agreement conflicts or is inconsistent with the terms, conditions and provisions of the Plan, the
Plan shall control, and this Agreement shall be deemed to be modified accordingly.

 

(
c ) Withholding. In connection with the common stock, the Participant agrees (a) to pay to the Company, or make arrangements satisfactory
to the Company regarding payment of, any federal, state or local, domestic or foreign taxes of any kind required by law to be
withheld in connection with the common stock and (b) that the Company shall, to the extent permitted by law, have the right to
deduct from any payment of any kind otherwise due to the Participant any federal, state or local taxes of any kind required by
law to be withheld with respect to the Participant.

 

(
d ) No Third-Party Beneficiaries. This Agreement shall not confer any rights or remedies upon any person other than the parties
and their respective successors and permitted assigns.

 

(
e ) Entire Agreement; Amendments. This Agreement constitutes the entire agreement among the parties and supersedes any prior understandings,
agreements, or representations by or among the parties, written or oral, that may have related in any way to the subject matter
hereof. Unless otherwise provided in the Plan or herein, this Agreement may not be amended, supplemented, or modified in whole
or in part except by an instrument in writing signed by the party or parties against whom enforcement of any such amendment, supplement,
or modification is sought.

 

(
f ) No Rights to Continued Employment. Not Compensation for Certain Purposes. Nothing contained herein shall give the Participant
the right to be retained in the employment or service of the Company or any of its subsidiaries or affiliates or affect the right
of any such employer to terminate the Participant. Any payment or benefit paid to the Participant with respect to this award shall
not be considered to be part of the Participant’s salary or compensation and thus, shall not be taken into account for purposes
of determining the Participant’s termination indemnity, severance pay, retirement or pension payment, or any other employee
benefits, except to the extent required under applicable law.

 

    	 	 	 

     

    

 

(g)
Counterparts. This Agreement may be executed in one or more counterparts, each of which will be deemed an original and all of
which together will constitute one and the same instrument

 

IN
WITNESS WHEREOF, the parties have executed this Agreement as of the day and year first above written.

 

	RENNOVA
    HEALTH, INC.:	 
	 	  	 
	By:
    	 	 
	Name:
    	Sebastien
    Sainsbury	 
	Title:
    	Corporate
    Secretary	 

 

	PARTICIPANT:	 
	 	               	 
	By:	 	 
	Name:
    	 	 
	Address:

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