Document:

Form of 3.184% Note due February 8, 2024

 Exhibit 4.1 

[Face of Note] 

UNLESS THIS CERTIFICATE IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF CDS CLEARING AND DEPOSITORY SERVICES INC.
(“CDS”) TO WELLS FARGO & COMPANY (THE “ISSUER”) OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE OR PAYMENT, AND ANY CERTIFICATE ISSUED IN RESPECT THEREOF IS REGISTERED IN THE NAME OF CDS & CO., OR IN SUCH
OTHER NAME AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF CDS (AND ANY PAYMENT IS MADE TO CDS & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF CDS), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR
OTHERWISE BY OR TO ANY PERSON IS WRONGFUL SINCE THE REGISTERED HOLDER HEREOF, CDS & CO., HAS A PROPERTY INTEREST IN THE SECURITIES REPRESENTED BY THIS CERTIFICATE HEREIN AND IT IS A VIOLATION OF ITS RIGHTS FOR ANOTHER PERSON TO HOLD,
TRANSFER OR DEAL WITH THIS CERTIFICATE. THIS CERTIFICATE IS ISSUED PURSUANT TO A BOOK ENTRY ONLY SECURITIES SERVICES AGREEMENT BETWEEN ISSUER AND CDS, AS SUCH AGREEMENT MAY BE REPLACED OR AMENDED FROM TIME TO TIME. 

UNLESS PERMITTED UNDER SECURITIES LEGISLATION, (A) OTHER THAN IN MANITOBA, THE HOLDER OF THIS SECURITY MUST NOT TRADE THE
SECURITY BEFORE THE DATE THAT IS 4 MONTHS AND A DAY AFTER THE LATER OF (I) FEBRUARY 8, 2019 AND (II) THE DATE THE ISSUER BECAME A REPORTING ISSUER IN ANY PROVINCE OR TERRITORY, AND (B) IN MANITOBA, THE HOLDER OF THIS SECURITY
MUST NOT TRADE THE SECURITY BEFORE THE DATE THAT IS 12 MONTHS AND A DAY AFTER FEBRUARY 8, 2019 OR UNTIL THE ISSUER FILES A PROSPECTUS FOR THE SECURITY. 

This Security is not a deposit or other obligation of a depository institution and is not insured by the Federal Deposit
Insurance Corporation, the Deposit Insurance Fund, the Canadian Deposit Insurance Fund or any other governmental agency. 
  

	 CUSIP NO. 949746SY8 
	
PRINCIPAL AMOUNT: CAD                  
           

 ISIN CA 949746SY82 

REGISTERED NO.      

WELLS FARGO & COMPANY 

3.184% Notes Due February 8, 2024 

WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware (hereinafter
called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay 

 
to CDS & CO., or registered assigns, the principal sum of ONE BILLION CANADIAN DOLLARS (CAD 1,000,000,000) on February 8, 2024 and to pay interest thereon from February 8,
2019 or from the most recent Interest Payment Date to which interest has been paid or duly provided for semi-annually on February 8 and August 8 of each year, commencing August 8, 2019, at the rate of 3.184% per annum, until the
principal hereof is paid or made available for payment. For a full semi-annual Interest Period, interest will be computed on the basis of a 360-day year of twelve 30-day
months. For an Interest Period that is not a full semi-annual Interest Period, interest will be computed on the basis of a 365-day year and the actual number of days in such Interest Period. With respect to
any Interest Payment Date, the “Interest Period” is the period commencing on and including the immediately preceding Interest Payment Date or, if none, February 8, 2019, and ending on and including the day immediately preceding that
Interest Payment Date. The interest so payable, and punctually paid or duly provided for, on any Interest Payment Date will, as provided in the Indenture, be paid to the Person in whose name this Security (or one or more Predecessor Securities) is
registered at the close of business on the Regular Record Date for such interest next preceding such Interest Payment Date. The Regular Record Date for an Interest Payment Date shall be the third Business Day immediately prior to such Interest
Payment Date. If an Interest Payment Date is not a Business Day, interest on this Security shall be payable on the next day that is a Business Day, with the same force and effect as if made on such Interest Payment Date, and without any interest or
other payment with respect to the delay. Interest payable upon Maturity will be paid to the Person to whom principal is payable. “Business Day” as used herein is a day, other than a Saturday or Sunday, that is neither a legal holiday nor a
day on which banking institutions are authorized or required by law or regulation or executive order to close in Toronto, Ontario, Canada or New York, New York, United States. 

If Canadian dollars are unavailable for payments on this Security, the Company will satisfy its obligations to make the
payments on this Security by making those payments on the date of payment in U.S. dollars on the basis of the Bank of Canada daily exchange rate (the “Market Exchange Rate”). If that rate of exchange is not then available or is not
published for Canadian dollars, the Market Exchange Rate will be based on the highest bid quotation in New York, New York received by the exchange rate agent at approximately 11:00 a.m., New York City time, on the second Business Day preceding
the applicable payment date from three recognized foreign exchange dealers for the purchase by the quoting dealer of Canadian dollars for U.S. dollars for settlement on the payment date in the aggregate amount of Canadian dollars payable to the
Holder of this Security and at which the applicable dealer commits to execute a contract. One of the dealers providing quotations may be the exchange rate agent appointed by the Company unless the exchange rate agent is an affiliate of the Company.
If those bid quotations are not available, the exchange rate agent will determine the Market Exchange Rate at its sole discretion. The Company will appoint an exchange rate agent in the event the Company is entitled to make payments on this Security
in U.S. dollars and will notify the Holder of this Security of such appointment. Any payment made in U.S. dollars as provided above where the required payment is in unavailable Canadian dollars will not constitute an Event of Default under the
Indenture. 
 Any interest not punctually paid or duly provided for will forthwith cease to be payable to the Holder on such
Regular Record Date and may either be paid to the Person in whose name this Security (or one or more Predecessor Securities) is registered at the close of business on a Special Record Date for the payment of such Defaulted Interest to be fixed by
the Trustee, notice whereof 

  
 2 

 
shall be given to Holders of Securities of this series not less than 10 days prior to such Special Record Date, or be paid at any time in any other lawful manner not inconsistent with the
requirements of any securities exchange on which the Securities of this series may be listed, and upon such notice as may be required by such exchange, all as more fully provided in the Indenture. 

Payment of interest on this Security will be made in immediately available funds at the office or agency of the Company
maintained for that purpose in Toronto, Ontario, Canada in Canadian dollars; provided, however, that, at the option of the Company, payment of interest may be paid by check mailed to the Person entitled thereto at such Person’s last address as
it appears in the Security Register or by wire transfer to such account as may have been designated by such Person. Any such designation for wire transfer purposes shall be made by providing written notice to the Paying Agent not later than 10
calendar days prior to the applicable Interest Payment Date. Payment of principal of and interest on this Security at Maturity will be made against presentation of this Security at the office or agency of the Company maintained for that purpose in
Toronto, Ontario, Canada. Notwithstanding the foregoing, for so long as this Security is a Global Security registered in the name of the Depositary, payments of principal and interest on this Security will be made to the Depositary by wire transfer
of immediately available funds. 
 The Paying Agent and Security Registrar for this Security is BNY Trust Company of Canada.
All notices to the Paying Agent under this Security shall be in writing and addressed to its corporate trust office at 1 York Street, 6th Floor, Toronto, Ontario, Canada M5J 0B6 or to such
other address as the Company may notify to the Holder of this Security. References in this Security to the office or agency of the Company in Toronto, Ontario, Canada are to the corporate trust office of the Paying Agent. 

The Company will pay any administrative costs imposed by banks on payors in making payments on this Security in immediately
available funds and the Holder of this Security will pay any administrative costs imposed by banks on payees in connection with such payments. Any tax, assessment or governmental charge imposed upon payments on this Security will be borne by the
Holder of this Security. 
 Reference is hereby made to the further provisions of this Security set forth on the reverse
hereof, which further provisions shall for all purposes have the same effect as if set forth at this place. 
 Unless the
certificate of authentication hereon has been executed by the Trustee referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall
not be entitled to any benefit under the Indenture or be valid or obligatory for any purpose. 

  
 3 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly
executed. 
 DATED: 
  

			
	WELLS FARGO & COMPANY

 
			
		
	By:	 	 

  

			
	Attest:	 	 

  

			
	 TRUSTEE’S CERTIFICATE OF

AUTHENTICATION
 This is one of the Securities of the

series designated therein referred to
 in the within-mentioned Indenture.

	
	 CITIBANK, N.A.,

      as Trustee

		
	By:	 	 
		 	Authorized Signature
	
	OR
	
	 BNY TRUST COMPANY OF CANADA,

  as Authenticating Agent for the Trustee

		
	By:	 	 
		 	Authorized Signature

 [Reverse of Note] 

WELLS FARGO & COMPANY 

3.184% Notes Due February 8, 2024 

This Security is one of a duly authorized issue of securities of the Company (herein called the “Securities”),
issued and to be issued in one or more series under an indenture dated as of February 21, 2017, as amended or supplemented from time to time (herein called the “Indenture”), between the Company and Citibank, N.A., as Trustee (herein
called the “Trustee,” which term includes any successor trustee under the Indenture), to which Indenture and all indentures supplemental thereto reference is hereby made for a statement of the respective rights, limitations of rights,
duties and immunities thereunder of the Company, the Trustee and the Holders of the Securities, and of the terms upon which the Securities are, and are to be, authenticated and delivered. This Security is one of the series designated on the face
hereof, limited in aggregate principal amount to CAD 1,000,000,000; provided, however, that the Company may, so long as no Event of Default has occurred and is continuing, without the consent of the Holders of the Securities of this series,
issue additional Securities with the same terms as the Securities of this series, and such additional Securities shall be considered part of the same series under the Indenture as the Securities of this series. 

The Securities of this series are not subject to repayment at the option of the Holder hereof prior to February 8, 2024.
The Securities of this series are redeemable at the option of the Company, subject to the prior approval of the Board of Governors of the Federal Reserve Board or other appropriate federal banking agency, (i) in whole, but not in part, in the
event that the Company becomes, or will become, obligated to pay any additional amounts as set forth below, and (ii) in whole at any time or in part from time to time on or after January 8, 2024, in each case at a Redemption Price equal to
100% of the principal amount of the Securities of this series to be redeemed, plus any accrued but unpaid interest to, but excluding, the Redemption Date. In the case of a partial redemption of the Securities of this series then held in book-entry
form, the Securities of this series to be redeemed will be selected by BNY Trust Company of Canada, in its capacity as Paying Agent, in accordance with the customary procedures of CDS. In the case of a partial redemption of the Securities of this
series, notice of redemption will be provided to the Paying Agent at least 15 days and not more than 60 days prior to the Redemption Date. The Securities of this series will not be entitled to any sinking fund. 

Subject to the exemptions and limitations set forth below, the Company will pay additional amounts on this Security in
Canadian dollars with respect to any beneficial owner of this Security that is a Non-U.S. Holder to ensure that each net payment to that Non-U.S. Holder on this Security
that it beneficially owns will not be less, due to the payment of United States withholding tax, than the amount then otherwise due and payable. In no event will the Company be obligated to pay additional amounts that exceed the amount required to
do so. For this purpose, a “net payment” on this Security means a payment by the Company, or any Paying Agent, including payment of principal and interest, after deduction for any present or future tax, assessment, or other

  
 5 

 
governmental charge of the United States. If paid, these additional amounts will constitute additional interest on the Securities of this series. 

As used in this Security, a “Non-U.S. Holder” is any beneficial owner of
this Security that, for U.S. federal income tax purposes, is not a U.S. Holder and that is not a partnership (or other entity treated as a partnership for U.S. federal income tax purposes). A “U.S. Holder” is a beneficial owner of this
Security that is, for U.S. federal income tax purposes, (i) an individual citizen or resident of the United States, (ii) a corporation (or any other entity treated as a corporation for U.S. federal income tax purposes) created or organized
in or under the laws of the United States, any state thereof or the District of Columbia, (iii) an estate whose income is subject to U.S. federal income tax regardless of its source, or (iv) a trust if (A) a United States court has
the authority to exercise primary supervision over the administration of the trust and one or more U.S. persons (as defined under the Internal Revenue Code of 1986, as amended (the “Code”)), are authorized to control all substantial
decisions of the trust or (B) it has a valid election in place to be treated as a U.S. person. An individual may, subject to certain exceptions, be deemed to be a resident of the United States by reason of being present in the United States for
a least 31 days in the calendar year and for an aggregate of at least 183 days during a three-year period ending in the current calendar year (counting for such purposes all of the days present in the current year,
one-third of the days present in the immediately preceding year and one-sixth of the days present in the second preceding year). “United States” means the
United States of America, including each state of the United States and the District of Columbia, its territories, its possessions, and other areas within its jurisdiction. 

The Company will not be required to pay additional amounts to a Non-U.S. Holder,
however, in any of the circumstances described in items (1) through (14) below. 

(1)    Additional amounts will not be payable if a payment on this Security is reduced as a result of any
tax, assessment, or other governmental charge that is imposed or withheld solely by reason of the beneficial owner: 
  

	 	•	 	 having a relationship with the United States as a citizen, resident, or otherwise; 

 

	 	•	 	 having had such a relationship in the past; or 

 

	 	•	 	 being considered as having had such a relationship. 

(2)    Additional amounts will not be payable if a payment on this Security is reduced as a result of any
tax, assessment, or other governmental charge that is imposed or withheld solely by reason of the beneficial owner: 
  

	 	•	 	 being treated as present in or engaged in a trade or business in the United States; 

  
 6 

	 	•	 	 being treated as having been present in or engaged in a trade or business in the United States in the past;

  

	 	•	 	 having or having had a permanent establishment in the United States; or 

 

	 	•	 	 having or having had a qualified business unit which has the U.S. dollar as its functional currency.

 (3)    Additional amounts will not be payable if a payment on this Security is
reduced as a result of any tax, assessment, or other governmental charge that is imposed or withheld solely by reason of the beneficial owner being or having been a (as each term is defined in the Code): 

 

	 	•	 	 personal holding company; 

 

	 	•	 	 foreign personal holding company; 

 

	 	•	 	 foreign private foundation or other foreign exempt organization; 

 

	 	•	 	 passive foreign investment company; 

 

	 	•	 	 controlled foreign corporation; or 

 

	 	•	 	 corporation which has accumulated taxable income to avoid U.S. federal income tax. 

(4)    Additional amounts will not be payable if a payment on this Security is reduced as a result of any
tax, assessment, or other governmental charge that is imposed or withheld solely by reason of the beneficial owner owning or having owned, actually or constructively, 10% or more of the total combined voting power of all classes of the
Company’s stock entitled to vote. 
 (5)    Additional amounts will not be payable if a payment on
this Security is reduced as a result of any tax, assessment, or other governmental charge that is imposed or withheld solely by reason of the beneficial owner being a bank that has invested in this Security as an extension of credit in the ordinary
course of business. 
 For purposes of items (1) through (5) above, “beneficial owner” includes a fiduciary,
settlor, partner, member, shareholder, or beneficiary of the holder if the holder is an estate, trust, partnership, limited liability company, corporation, or other entity, or a person holding a power over an estate or trust administered by a
fiduciary holder. 

  
 7 

 (6)    Additional amounts will not be payable to any
beneficial owner of this Security that is: 
  

	 	•	 	 a fiduciary; 

  

	 	•	 	 a partnership; 

  

	 	•	 	 a limited liability company; 

 

	 	•	 	 another fiscally transparent entity; or 

 

	 	•	 	 not the sole beneficial owner of this Security, or any portion of this Security. 

However, this exception to the obligation to pay additional amounts will apply only to the extent that a beneficiary or settlor in relation to
the fiduciary, or a beneficial owner, partner, or member of the partnership, limited liability company, or other fiscally transparent entity, would not have been entitled to the payment of an additional amount had the beneficiary, settlor,
beneficial owner, partner, or member received directly its beneficial or distributive share of the payment. 

(7)     Additional amounts will not be payable if a payment on this Security is reduced as a result of any
tax, assessment, or other governmental charge that is imposed or withheld by reason of the failure of the beneficial owner or any other person to comply with applicable certification, identification, documentation, or other information reporting
requirements. 
 (8)     Additional amounts will not be payable if a payment on this Security is reduced
as a result of any tax, assessment, or other governmental charge that is collected or imposed by any method other than by withholding from a payment on this Security by the Company or the Paying Agent. 

(9)     Additional amounts will not be payable if a payment on this Security is reduced as a result of any
tax, assessment, or other governmental charge that is imposed or withheld by reason of a change in law, regulation, or administrative or judicial interpretation that becomes effective more than 15 days after the payment becomes due or is duly
provided for, whichever occurs later. 
 (10)     Additional amounts will not be payable if a payment on
this Security is reduced as a result of any tax, assessment, or other governmental charge that is imposed or withheld by reason of the presentation by the beneficial owner for payment more than 30 days after the date on which such payment becomes
due or is duly provided for, whichever occurs later. 
 (11)     Additional amounts will not be payable
if a payment on this Security is reduced as a result of any: 
  

	 	•	 	 estate tax; 

  
 8 

	 	•	 	 inheritance tax; 

  

	 	•	 	 gift tax; 

  

	 	•	 	 sales tax; 

  

	 	•	 	 excise tax; 

  

	 	•	 	 transfer tax; 

  

	 	•	 	 wealth tax; 

  

	 	•	 	 personal property tax; or 

 

	 	•	 	 any similar tax, assessment, withholding, deduction or other governmental charge. 

(12)     Additional amounts will not be payable if a payment on this Security is reduced as a result of
any tax, assessment, or other governmental charge required to be withheld by any Paying Agent from a payment of principal or interest on this Security if that payment can be made without such withholding by any other Paying Agent. 

(13)     Additional amounts will not be payable if payment on this Security or in respect to this Security
is reduced as a result of any tax, withholding, assessment or other governmental charge that is required to be paid or withheld from any payment under Code sections 1471 through 1474 (or any amended or successor provisions) and any regulations
or official interpretations thereof or any law, agreement or regulations implementing an intergovernmental approach thereto. 

(14)     Additional amounts will not be payable if a payment on this Security is reduced as a result of
any withholding, deduction, tax, duty assessment or other governmental charge that would not have been imposed but for a failure by the Holder or beneficial owner of this Security (or any financial institution through which the Holder or beneficial
owner holds this Security or through which payment on this Security is made) to comply with any applicable certification, documentation, information or other reporting requirement or agreement concerning accounts maintained by the Holder or
beneficial owner (or any such financial institution), or concerning ownership of the Holder or beneficial owner, or any substantially similar requirement or agreement. 

(15)     Additional amounts will not be payable if a payment on this Security is reduced as a result of
any combination of items (1) through (14) above. 
 Except as specifically provided above, the Company will not be required to make any
payment of any tax, assessment, or other governmental charge imposed by any government, political subdivision, or taxing authority of that government. 

  
 9 

 If an Event of Default, as defined in the Indenture, with respect to
Securities of this series shall occur and be continuing, the principal of the Securities of this series may be declared due and payable in the manner and with the effect provided in the Indenture. 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights
and obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the time Outstanding of all series to be affected, acting together. The Indenture also contains provisions permitting the Holders of a majority in principal amount of the Securities of all series at the time Outstanding affected by
certain provisions of the Indenture, acting together, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain past defaults under the Indenture and their
consequences may be waived under the Indenture by the Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such series. Any such consent or waiver by the
Holder of this Security shall be conclusive and binding upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not
notation of such consent or waiver is made upon this Security. 
 The Indenture contains provisions for defeasance at any
time of (a) the entire indebtedness on this Security and (b) certain restrictive covenants, upon compliance by the Company with certain conditions set forth therein, which provisions apply to this Security. 

Upon due presentment for registration of transfer of this Security at the office or agency of the Company in Toronto, Ontario,
Canada, a new Security or Securities of this series in authorized denominations for an equal aggregate principal amount will be issued to the transferee in exchange herefor, as provided in the Indenture and subject to the limitations provided
therein and to the limitations described below, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is issuable only in registered form without coupons in denominations of CAD 5,000 and integral multiples of CAD
1,000 in excess thereof and cannot be exchanged for debt securities of the Company in smaller denominations. Beneficial interests in this Security will only be held in denominations of CAD 5,000 and integral multiples of CAD 1,000 in excess thereof.

 Upon due presentment for registration of transfer of this Security at the office or agency of the Company in Toronto,
Ontario, Canada, a new Security or Securities of this series in authorized denominations for an equal aggregate principal amount will be issued to the transferee in exchange herefor, as provided in the Indenture and subject to the limitations
provided therein and to the limitations described herein, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is exchangeable for definitive Securities in registered form only if (i) the Company is required to do so
by law, (ii) CDS ceases to exist, (iii) the Company determines that CDS is no longer willing or able to discharge properly its responsibilities as depository with respect 

  
 10 

 
to this Security, and the Company is unable to locate a qualified successor, (iv) at the option of the Company the Company elects to terminate the book-entry only system through the CDS or
(v) an Event of Default under the Indenture with respect to this Security has occurred or is continuing. If this Security is exchangeable pursuant to the preceding sentence, it shall be exchangeable for definitive Securities in registered form,
bearing interest at the same rate, having the same date of issuance, redemption provisions, Stated Maturity Date and other terms and of authorized denominations aggregating a like amount. 

This Security may not be transferred except as a whole by the Depositary to a nominee of the Depositary or by a nominee of the
Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor. Except as provided above, owners of beneficial interests in this global
Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture. 

No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation
of the Company, which is absolute and unconditional, to pay the principal of and interest on this Security at the times, place and rate, and in the coin or currency, herein prescribed, except as otherwise provided in this Security and except that in
the event the Company deposits money or Eligible Instruments as provided in Articles 4 and 15 of the Indenture, such payments will be made only from proceeds of such money or Eligible Instruments. 

Prior to due presentment of this Security for registration of transfer, the Company, the Trustee and any agent of the Company
or the Trustee may treat the Person in whose name this Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 No recourse shall be had for the payment of the principal of or the interest on this Security, or for any claim
based hereon, or otherwise in respect hereof, or based on or in respect of the Indenture or any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or any
successor corporation, whether by virtue of any constitution, statute or rule of law, or by the enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance hereof and as part of the consideration for the
issuance hereof, expressly waived and released. 
 All terms used in this Security which are defined in the Indenture shall
have the meanings assigned to them in the Indenture unless otherwise defined in this Security. 
 This Security shall be
governed by and construed in accordance with the law of the State of New York, without regard to principles of conflicts of laws. 

  
 11 

 ABBREVIATIONS 

The following abbreviations, when used in the inscription on the face of this instrument, shall be construed as though they
were written out in full according to applicable laws or regulations: 
  

					
	 TEN COM
	 	  -- 
	 	 as tenants in common

			
	 TEN ENT
	 	  -- 
	 	 as tenants by the entireties

			
	 JT TEN
	 	  -- 
	 	 as joint tenants with right

of survivorship and not
 as
tenants in common

  

							
	 UNIF GIFT MIN ACT -- 
	 	 	 	 Custodian
	 	 
		 	(Cust)	 		 	(Minor)

  

	
	Under Uniform Gifts to Minors Act
	
	    
	(State)

 Additional abbreviations may also be used though not in the above list. 

FOR VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 

 

	
	 Please Insert Social Security or
 Other
Identifying Number of Assignee

	
	   

  
  

 
  
  

 
 (PLEASE
PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL ZIP CODE OF ASSIGNEE)

  
 12 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute
and appoint                                      attorney to
transfer the said Security on the books of the Company, with full power of substitution in the premises. 
 Dated:
                                         
        
  

	
	    

  

	
	    

 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the
within instrument in every particular, without alteration or enlargement or any change whatever. 
  

	
	    
	Signature Guarantee

  
 13THE
REGISTERED HOLDER OF THIS UNIT PURCHASE OPTION BY ITS ACCEPTANCE HEREOF, AGREES THAT THE SECURITIES EVIDENCED BY THIS UNIT PURCHASE
OPTION MAY NOT BE SOLD, TRANSFERED OR ASSIGNED EXCEPT AS HEREIN PROVIDED AND THE REGISTERED HOLDER OF THIS UNIT PURCHASE OPTION
AGREES THAT THE SECURITIES EVIDENCED BY THIS UNIT PURCHASE OPTION WILL NOT BE SOLD, TRANSFERED, ASSIGNED, PLEDGED OR HYPOTHECATED,
OR BE THE SUBJECT OF ANY HEDGING, SHORT SALE, DERIVATIVE, PUT, OR CALL TRANSACTION THAT WOULD RESULT IN THE EFFECTIVE ECONOMIC
DISPOSITION OF THIS UNIT PURCHASE OPTION OR THE SECURITIES EVIDENCED BY THIS UNIT PURCHASE OPTION, FOR A PERIOD OF ONE HUNDRED
EIGHTY (180) DAYS FOLLOWING THE EFFECTIVE DATE (DEFINED BELOW) TO ANYONE OTHER THAN TO ANY MEMBER PARTICIPATING IN THE OFFERING
AND THE OFFICERS OR PARTNERS THEREOF, IF ALL SECURITIES SO TRANSFERRED REMAIN SUBJECT TO THE LOCK-UP RESTRICTION SET FORTH ABOVE
FOR THE REMAINDER OF THE TIME PERIOD.

 

UNIT
PURCHASE OPTION

 

FOR THE PURCHASE OF [●] UNITS

 

OF
IMAC HOLDINGS, INC.

 

1.
Unit Purchase Option.

 

THIS CERTIFIES THAT, in
consideration of $100.00 duly paid by or on behalf of [  ] (“Holder”), as registered owner of this Unit
Purchase Option, to IMAC Holdings, Inc. (the “Company”), Holder is entitled, at any time or from time to time commencing
on the 180th day after the effective date (the “Effective Date”) of the registration statement (the “Registration
Statement”) pursuant to which certain units of securities are offered for sale to the public (the “Offering”)
(the “Commencement Date”), and at or before 5:00 p.m., Eastern Time, on the fifth anniversary of the Effective Date
(the “Expiration Date”), but not thereafter, to subscribe for, purchase and receive, in whole or in part, up to [●]1
units (the “Units”) of the Company, each Unit consisting of one share of the Company’s common stock, par
value $0.001 per share (the “Shares”) and two warrant s, each to purchase one Share (the “Warrant(s)”).
Each Warrant is the same as the warrants included in the Units being registered for sale to the public (the “Public Warrants”)
under the Securities Act of 1933, as amended (the “Act”). If the Expiration Date is a day on which banking institutions
are authorized by law to close, then this Unit Purchase Option may be exercised on the next succeeding day which is not such a
day in accordance with the terms herein. During the period ending on the Expiration Date, the Company agrees not to take any action
that would terminate the Unit Purchase Option. This Unit Purchase Option is initially exercisable at $[●] per Unit (or 120%
of the public offering price of the unit of securities being sold in the Offering) so purchased; provided, however, that upon
the occurrence of any of the events specified in Section 5 hereof, the rights granted by this Unit Purchase Option, including
the exercise price per Unit and the number of Units to be received upon such exercise, shall be adjusted as therein specified.
The term “Exercise Price” shall mean the initial exercise price or the adjusted exercise price, depending on the context.

 

2.
Exercise.

 

(a)
Exercise Procedure. In order to exercise this Unit Purchase Option, the exercise form attached hereto must be duly executed and
completed and delivered to the Company, together with this Unit Purchase Option and payment of the Exercise Price for the Units
being purchased payable in cash or by certified check or official bank check. If the subscription rights represented hereby shall
not be exercised at or before 5:00 p.m., Eastern time, on the Expiration Date, this Unit Purchase Option shall become and be void
without further force or effect, and all rights represented hereby shall cease and expire.

 

(b)
Legend. If required by applicable law at the time of any exercise, each certificate for the securities purchased under this Unit
Purchase Option shall bear a legend as follows unless such securities have been registered under the Act:

 

 

1
[Insert 4% of units issued excluding overallotment]

 

    	 

    	 

    

 

“The
securities represented by this certificate have not been registered under the Securities Act of 1933, as amended (the “Act”)
or applicable state law. The securities may not be offered for sale, sold or otherwise transferred except pursuant to an effective
registration statement under the Act, or pursuant to an exemption from registration under the Act and applicable state law.”

 

(c)
Cashless Exercise.

 

(i)
In lieu of the payment of the Exercise Price multiplied by the number of Units for which this Unit Purchase Option is exercisable
(and in lieu of being entitled to receive Shares and Warrants) in the manner required by Section 2(a), the Holder shall have the
right (but not the obligation) to convert any exercisable but unexercised portion of this Unit Purchase Option into Units consisting
of Shares and Warrants (the “Conversion Right”) as follows:

 

(A)
Upon exercise of the Conversion Right, the Company shall deliver to the Holder (without payment by the Holder of any of the Exercise
Price in cash) that number of Shares equal to the quotient obtained by dividing (x) the Value of the portion of the Unit Purchase
Option being converted by (y) the Current Market Price of a Share.

 

(B)
The “Value” of the portion of the Unit Purchase Option being converted shall equal the remainder derived by subtracting
(a) (i) the Exercise Price multiplied by (ii) the number of Units underlying the portion of this Unit Purchase Option being converted,
from (b) the Current Market Value of a Unit multiplied by the number of Units underlying the portion of the Unit Purchase Option
being converted.

 

(C)
As used herein, the term “Current Market Value” per Unit at any date means the remainder derived by subtracting (x)
the exercise price of the Warrants multiplied by the number of Shares issuable upon exercise of the Warrants underlying one Unit
from (y) the Current Market Price of the Shares multiplied by the number of Shares included within one Unit and underlying the
Warrants included within one Unit.

 

(D)
The “Current Market Price” of a Share shall mean (i) if the Shares are listed on a national securities exchange or
quoted on the OTCQB or OTCQX (or any successor exchange or entity), the closing or last sale price of the Shares in the principal
trading market for the Shares on the last trading day preceding the day in question as reported by the exchange, the OTCQB or
OTCQX, as the case may be; (ii) if the Shares are not listed on a national securities exchange or quoted on the OTCQB or OTCQX,
but are traded in the residual over-the-counter market, the closing bid price for the Shares on the last trading day preceding
the date in question for which such quotations are reported in the “Pink Sheets” published by OTC Markets Group, Inc.
or similar publisher of such quotations; and (iii) if the fair market value of the Shares cannot be determined pursuant to clause
(i) or (ii) above, such price as the Board of Directors of the Company shall determine, in good faith.

 

(ii)
The Cashless Exercise Right may be exercised by the Holder on any business day on or after the Commencement Date and not later
than the Expiration Date by delivering the Unit Purchase Option with the duly executed exercise form attached hereto with the
cashless exercise section completed to the Company, exercising the Cashless Exercise Right and specifying the total number of
Units the Holder will purchase pursuant to such Cashless Exercise Right.

 

    	2

    	 

    

 

(d) Resale of Shares.
Holder and the Company acknowledge that as of the date hereof the Staff of the Division of Corporation Finance of the SEC has
published Compliance & Disclosure Interpretation 528.04 in the Securities Act Rules section thereof, stating that the holder
of securities issued in connection with a public offering may not rely upon Rule 144 promulgated under the Act to establish an
exemption from registration requirements under Section 4(1) under the Act, but may nonetheless apply Rule 144 constructively for
the resale of such shares in the following manner: (a) provided that six months has elapsed since the last sale under the registration
statement, an underwriter or finder may resell the securities in accordance with the provisions of Rule 144(c), (e), and (f),
except for the notice requirement; (b) a purchaser of the shares from an underwriter receives restricted securities unless the
sale is made with an appropriate, current prospectus, or unless the sale is made pursuant to the conditions contained in (a) above;
(c) a purchaser of the shares from an underwriter who receives restricted securities may include the underwriter’s holding
period, provided that the underwriter or finder is not an affiliate of the issuer; and (d) if an underwriter transfers the shares
to its employees, the employees may tack the firm’s holding period for purposes of Rule 144(d), but they must aggregate
sales of the distributed shares with those of other employees, as well as those of the underwriter or finder, for a six-month
period from the date of the transfer to the employees. Holder and the Company also acknowledge that the Staff of the Division
of Corporation Finance of the SEC has advised in various no-action letters that the holding period associated with securities
issued without registration to a service provider commences upon the completion of the services, which the Company agrees and
acknowledges shall be the closing of the Offering, and that Rule 144(d)(3)(ii) provides that securities acquired from the issuer
solely in exchange for other securities of the same issuer shall be deemed to have been acquired at the same time as the securities
surrendered for conversion (which the Company agrees is the date of the initial issuance of this Unit Purchase Option). In the
event that following a request by Holder to transfer the Shares in accordance with Compliance & Disclosure Interpretation
528.04 counsel for the Company reasonably concludes that Compliance & Disclosure Interpretation 528.04 no longer may be relied
upon as a result of changes in applicable laws, regulations, or interpretations of the SEC Division of Corporation Finance, or
as a result of judicial interpretations not known by the Company or its counsel on the date hereof (either, a “Registration
Trigger Event”), then the Company shall promptly, and in any event within five (5) business days following the request,
provide written notice to Holder of such determination. As a condition to giving such notice, the Company shall offer Holder a
single “piggyback” registration right pursuant to an agreement in form reasonably acceptable to the Holder;
provided that notwithstanding anything to the contrary, the obligations of the Company pursuant to this Section 2 shall terminate
on the fifth anniversary of the effective date of the Registration Statement pursuant to which the Offering is being made. In
the absence of such conclusion by counsel for the Company, the Company shall, upon request of Holder given no earlier than six
months after the final closing of the Offering, instruct its transfer agent to permit the transfer of such shares in accordance
with Compliance & Disclosure Interpretation 528.04, provided that Holder has provided such documentation as shall be reasonably
be requested by the Company to establish compliance with the conditions of Compliance & Disclosure Interpretation 528.04.
Notwithstanding anything to the contrary, pursuant to FINRA Rule 5110(f)(2)(G)(iv), the Holder shall not be entitled to more than
one “piggyback” registration right hereunder and the duration of the registration rights hereunder shall not
exceed five years from the Effective Date.

 

3.
Transfer.

 

(a)
Restrictions—General. The securities evidenced by this Unit Purchase Option shall not be sold, transferred, assigned,
pledged or hypothecated, or be the subject of any hedging, short sale, derivative, put, or call transaction that would result
in the effective economic disposition of, this Unit Purchase Option (or any securities underlying this Unit Purchase Option) for
a period of one hundred eighty (180) days following the Effective Date to anyone other than to any member participating in the
offering and the officers or partners thereof, if all securities so transferred remain subject to the lock-up restriction set
forth above for the remainder of the time period. In order to make any permitted assignment, the Holder must deliver to the Company
the assignment form attached hereto duly executed and completed, together with the Unit Purchase Option and payment of all transfer
taxes, if any, payable in connection therewith. The Company shall within three business days transfer this Unit Purchase Option
on the books of the Company and shall execute and deliver a new Unit Purchase Option or Unit Purchase Options of like tenor to
the appropriate assignee(s) expressly evidencing the right to purchase the aggregate number of Units purchasable hereunder or
such portion of such number as shall be contemplated by any such assignment.

 

(b)
Restrictions—Securities. The securities evidenced by this Unit Purchase Option shall not be transferred unless and
until (i) the Company has received the opinion of counsel for the Holder that the securities may be transferred pursuant to an
exemption from registration under the Act and applicable state securities laws, the availability of which is established to the
reasonable satisfaction of the Company, or (ii) a registration statement or a post-effective amendment to the Registration Statement
relating to such securities has been filed by the Company and declared effective by the Securities and Exchange Commission (the
“Commission”) and compliance with applicable state securities law has been established.

 

    	3

    	 

    

 

4.
New Unit Purchase Options to be Issued.

 

(a)
Partial Exercise. Subject to the restrictions in Section 3 hereof, this Unit Purchase Option may be exercised or assigned
in whole or in part. In the event of the exercise or assignment hereof in part only, upon surrender of this Unit Purchase Option
for cancellation, together with the duly executed exercise or assignment form and funds sufficient to pay any Exercise Price,
the Company shall cause to be delivered to the Holder without charge a new Unit Purchase Option of like tenor to this Unit Purchase
Option in the name of the Holder evidencing the right of the Holder to purchase the number of Units purchasable hereunder as to
which this Unit Purchase Option has not been exercised or assigned.

 

(b)
Loss, Theft, Destruction. Upon receipt by the Company of evidence satisfactory to it of the loss, theft, destruction or
mutilation of this Unit Purchase Option and of reasonably satisfactory indemnification or the posting of a bond, the Company shall
execute and deliver a new Unit Purchase Option of like tenor and date. Any such new Unit Purchase Option executed and delivered
as a result of such loss, theft, mutilation or destruction shall constitute a substitute contractual obligation on the part of
the Company.

 

5.
Adjustments.

 

(a)
Exercise Price and Number of Securities. The Exercise Price and the number of Units underlying the Unit Purchase Option
shall be subject to adjustment from time to time as hereinafter set forth:

 

(i)
If after the date hereof, and subject to the provisions of Section 5(c) below, the number of outstanding Shares is increased by
a stock dividend payable in Shares or by a split-up of Shares or other similar event, then, on the effective date thereof, the
number of Shares underlying each of the Units purchasable hereunder shall be increased in proportion to such increase in outstanding
shares. In such case, the number of Shares, and the exercise price applicable thereto, underlying the Warrants underlying each
of the Units purchasable hereunder shall be adjusted in accordance with the terms of the Warrants. For example, if the Company
declares a two-for-one stock dividend and immediately prior to such dividend this Unit Purchase Option is for the purchase of
one Unit at $10.00 per whole Unit (with each Warrant underlying the Units being exercisable for $12.00 per share), upon effectiveness
of the dividend, this Unit Purchase Option will be adjusted to allow for the purchase of one Unit at $10.00 per Unit, each Unit
entitling the holder to receive two Shares and two Warrants (each Warrant exercisable for $6.00 per share).

 

(ii)
If after the date hereof, and subject to the provisions of Section 5(c), the number of outstanding Shares is decreased by a consolidation,
combination or reclassification of the Shares or other similar event, then, on the effective date thereof, the number of Shares
underlying each of the Units purchasable hereunder shall be decreased in proportion to such decrease in outstanding shares. In
such case, the number of Shares, and the exercise price applicable thereto, issuable upon exercise of the Warrants included in
each of the Units purchasable hereunder shall be adjusted in accordance with the terms of the Warrants. For example, if the Company
effects a one-for-two stock reverse stock split and immediately prior to such stock split this Unit Purchase Option is for the
purchase of one Unit at $10.00 per whole Unit (with each Warrant underlying the Units being exercisable for $12.00 per share),
upon effectiveness of the stock split, this Unit Purchase Option will be adjusted to allow for the purchase of one Unit at $10.00
per Unit, each Unit entitling the holder to receive 0.5 Shares and 0.5 Warrants (each Warrant exercisable for $24.00 per share).

 

(iii)
In case of any reclassification or reorganization of the outstanding Shares other than a change covered by Section 5(a)(i) or
5(a)(ii) hereof or that solely affects the par value of such Shares, or in the case of any merger or consolidation of the Company
with or into another corporation (other than a consolidation or merger in which the Company is the continuing corporation and
that does not result in any reclassification or reorganization of the outstanding Shares), or in the case of any sale or conveyance
to another corporation or entity of the property of the Company as an entirety or substantially as an entirety in connection with
which the Company is dissolved, the Holder of this Unit Purchase Option shall have the right thereafter (until the expiration
of the right of exercise of this Unit Purchase Option) to receive upon the exercise hereof, for the same aggregate Exercise Price
payable hereunder immediately prior to such event plus the aggregate exercise price of the Shares underlying the Warrants immediately
prior to such event, the kind and amount of shares of stock or other securities or property (including cash) receivable upon such
reclassification, reorganization, merger or consolidation, or upon a dissolution following any such sale or transfer, by a Holder
of the number of Shares of the Company obtainable upon exercise of this Unit Purchase Option and the underlying Warrants immediately
prior to such event; and if any reclassification also results in a change in Shares covered by Section 5(a)(i) or 5(a)(ii), then
such adjustment shall be made pursuant to Sections 5(a)(i) or 5(a)(ii) and this Section 5(a)(iii). The provisions of this Section
5(a)(iii) shall similarly apply to successive reclassifications, reorganizations, mergers or consolidations, sales or other transfers.

 

    	4

    	 

    

 

(iv)
This form of Unit Purchase Option need not be changed because of any change pursuant to this Section 5, and Unit Purchase Options
issued after such change may state the same Exercise Price and the same number of Units as are stated in the Unit Purchase Options
initially issued pursuant to this Agreement. The acceptance by any Holder of the issuance of new Unit Purchase Options reflecting
a required or permissive change shall not be deemed to waive any rights to an adjustment occurring after the Commencement Date
or the computation thereof.

 

(b)
Substitute Unit Purchase Option. In case of any consolidation of the Company with, or merger of the Company with, or merger
of the Company into, another corporation (other than a consolidation or merger which does not result in any reclassification or
change of the outstanding Shares), the corporation formed by such consolidation or merger shall execute and deliver to the Holder
a supplemental Unit Purchase Option providing that the holder of each Unit Purchase Option then outstanding or to be outstanding
shall have the right thereafter (until the stated expiration of such Unit Purchase Option) to receive, upon exercise of such Unit
Purchase Option, the kind and amount of shares of stock and other securities and property receivable upon such consolidation or
merger, by a holder of the number of Shares of the Company for which such Unit Purchase Option might have been exercised immediately
prior to such consolidation, merger, sale or transfer. Such supplemental Unit Purchase Option shall provide for adjustments which
shall be identical to the adjustments provided in this Section 5. The above provision of this Section 5 shall similarly apply
to successive consolidations or mergers.

 

(c)
Fractional Interests. The Company shall not be required to issue certificates representing fractions of Shares or Warrants
upon the exercise of the Unit Purchase Option, nor shall it be required to issue scrip or pay cash in lieu of any fractional interests,
it being the intent of the parties that all fractional interests shall be eliminated by rounding any fraction up to the nearest
whole number of Warrants, Shares or other securities, properties or rights.

 

6.
Reservation and Listing. The Company shall at all times reserve and keep available out of its authorized Shares, solely for
the purpose of issuance upon exercise of the Warrants underlying the Unit Purchase Option, such number of Shares or other securities,
properties or rights as shall be issuable upon the conversion or exercise thereof. The Company further covenants and agrees that
upon exercise of the Warrants underlying the Unit Purchase Option and payment of the respective Warrant exercise price therefor,
all Shares and other securities issuable upon such exercise shall be duly and validly issued, fully paid and non-assessable and
not subject to preemptive rights of any stockholder. As long as the Unit Purchase Option shall be outstanding, the Company shall
use its best efforts to cause all Shares issuable upon exercise of the Warrants included in the Units issuable upon exercise of
the Unit Purchase Option to be listed (subject to official notice of issuance) on all securities exchanges (or, if applicable
on the OTC Bulletin Board or any successor trading market) on which the Shares issued to the public in connection with the Offering
may then be listed and/or quoted.

 

7.
Certain Notice Requirements.

 

(a)
Right to Notice. Nothing herein shall be construed as conferring upon the Holders the right to vote or consent as a stockholder
for the election of directors or any other matter, or as having any rights whatsoever as a stockholder of the Company. If, however,
at any time prior to the expiration of the Unit Purchase Option and its exercise, any of the events described in Section 7(b)
shall occur, then, in one or more of said events, the Company shall give written notice of such event at least fifteen days prior
to the date fixed as a record date or the date of closing the transfer books for the determination of the stockholders entitled
to such dividend, distribution, conversion or exchange of securities or subscription rights, or entitled to vote on such proposed
dissolution, liquidation, winding up or sale. Such notice shall specify such record date or the date of the closing of the transfer
books, as the case may be. Notwithstanding the foregoing, the Company shall deliver to each Holder a copy of each notice given
to the other stockholders of the Company with respect to the events enumerated in Section 7(b) at the same time and in the same
manner that such notice is given to all stockholders, even if less than fifteen days.

 

    	5

    	 

    

 

(b)
Enumerated Events. The Company shall be required to give the notice described in this Section 7 upon one or more of the
following events: (i) if the Company shall take a record of the holders of its Shares for the purpose of entitling them to receive
a dividend or distribution payable otherwise than in cash, or a cash dividend or distribution payable otherwise than out of retained
earnings, as indicated by the accounting treatment of such dividend or distribution on the books of the Company, or (ii) the Company
shall offer to all the holders of its Shares any additional shares of capital stock of the Company or securities convertible into
or exchangeable for shares of capital stock of the Company, or any option, right or warrant to subscribe therefor, or (iii) a
dissolution, liquidation or winding up of the Company (other than in connection with a consolidation or merger) or a sale of all
or substantially all of its property, assets and business shall be proposed.

 

(c)
Change in Exercise Price. The Company shall, promptly after an event requiring a change in the Exercise Price pursuant
to Section 5 hereof, send notice to the Holders of such event and change (the “Price Notice”). The Price Notice shall
describe the event causing the change and the method of calculating same and shall be certified as being true and accurate by
the Company’s President and Chief Financial Officer.

 

(d)
Notice Delivery. All notices, requests, consents and other communications under this Unit Purchase Option shall be in writing
and shall be deemed to have been duly made when hand delivered, or mailed by express mail or private courier service: (i) If to
the registered Holder of the Unit Purchase Option, to the address of such Holder as shown on the books of the Company, or (ii)
If to the Company, to the following address or to such other address as the Company may designate by notice to the Holders:

 

IMAC
Holdings, Inc.

1605 Westgate Circle

Brentwood,
Tennessee 37027

Attn: Chief Executive Officer

 

8.
Reserved.

 

9.
Miscellaneous.

 

(a) Amendments.
The Company and Dawson James Securities, Inc. (“Dawson”) may from time to time supplement or amend this
Unit Purchase Option without the approval of any of the Holders in order to cure any ambiguity, to correct or supplement any provision
contained herein that may be defective or inconsistent with any other provisions herein, or to make any other provisions in regard
to matters or questions arising hereunder that the Company and Dawson may deem necessary or desirable and that the Company
and Dawson deem shall not adversely affect the interest of the Holders. All other modifications or amendments shall require
the written consent of and be signed by the party against whom enforcement of the modification or amendment is sought.

 

(b)
Headings. The headings contained herein are for the sole purpose of convenience of reference, and shall not in any way
limit or affect the meaning or interpretation of any of the terms or provisions of this Unit Purchase Option.

 

(c)
Entire Agreement. This Unit Purchase Option (together with the other agreements and documents being delivered pursuant
to or in connection with this Unit Purchase Option) constitutes the entire agreement of the parties hereto with respect to the
subject matter hereof, and supersedes all prior agreements and understandings of the parties, oral and written, with respect to
the subject matter hereof.

 

(d)
Binding Effect. This Unit Purchase Option shall inure solely to the benefit of, and shall be binding upon, the Holder and
the Company and their permitted assignees, respective successors, legal representative and assigns, and no other person shall
have or be construed to have any legal or equitable right, remedy or claim under or in respect of or by virtue of this Unit Purchase
Option or any provisions herein contained.

 

    	6

    	 

    

 

(e)
Governing Law. This Unit Purchase Option shall be governed by and construed and enforced in accordance with the laws of
the State of New York, without giving effect to conflict of laws. The Company hereby agrees that any action, proceeding or claim
against it arising out of, or relating in any way to this Unit Purchase Option shall be brought and enforced in the courts of
the State of New York or of the United States of America for the Southern District of New York, and irrevocably submits to such
jurisdiction, which jurisdiction shall be exclusive. The Company hereby waives any objection to such exclusive jurisdiction and
that such courts represent an inconvenient forum. Any process or summons to be served upon the Company may be served by transmitting
a copy thereof by registered or certified mail, return receipt requested, postage prepaid, addressed to it at the address set
forth in Section 7 hereof. Such mailing shall be deemed personal service and shall be legal and binding upon the Company in any
action, proceeding or claim. The Company and the Holder agree that the prevailing party(ies) in any such action shall be entitled
to recover from the other party(ies) all of its reasonable attorneys’ fees and expenses relating to such action or proceeding
and/or incurred in connection with the preparation therefor.

 

(f)
Waivers. The failure of the Company or the Holder to at any time enforce any of the provisions of this Unit Purchase Option
shall not be deemed or construed to be a waiver of any such provision, nor to in any way affect the validity of this Unit Purchase
Option or any provision hereof or the right of the Company or any Holder to thereafter enforce each and every provision of this
Unit Purchase Option. No waiver of any breach, non-compliance or non-fulfillment of any of the provisions of this Unit Purchase
Option shall be effective unless set forth in a written instrument executed by the party or parties against whom or which enforcement
of such waiver is sought; and no waiver of any such breach, non-compliance or non-fulfillment shall be construed or deemed to
be a waiver of any other or subsequent breach, non-compliance or non-fulfillment.

 

(g)
Counterparts. This Unit Purchase Option may be executed in one or more counterparts, and by the different parties hereto
in separate counterparts, each of which shall be deemed to be an original, but all of which taken together shall constitute one
and the same agreement, and shall become effective when one or more counterparts has been signed by each of the parties hereto
and delivered to each of the other parties hereto. Such counterparts may be delivered by facsimile transmission or other electronic
transmission.

 

(h) Exchange Agreement.
As a condition of the Holder’s receipt and acceptance of this Unit Purchase Option, Holder agrees that, at any time
prior to the complete exercise of this Unit Purchase Option by Holder, if the Company and Dawson enter into an agreement
(the “Exchange Agreement”) pursuant to which they agree that all outstanding Unit Purchase Options will be exchanged
for securities or cash or a combination of both, then Holder shall agree to such exchange and become a party to the Exchange Agreement.

 

[Balance
of page intentionally left blank]

 

    	7

    	 

    

 

IN
WITNESS WHEREOF, the Company has caused this Unit Purchase Option to be signed by its duly authorized officer as of the
[●] day of [●], 2019.

 

	 	IMAC
    Holdings, Inc.
	 	 	 
	 	By:	         
	 	Name:	 
	 	Title:	 

 

    	 

    	 

    

 

Form
To Be Used To Exercise Unit Purchase Option

 

IMAC
Holdings, Inc.

1605 Westgate Circle

Brentwood,
Tennessee 37027

 

Attn:
Chief Executive Officer

 

Date:        ,
20__

 

The
undersigned hereby elects irrevocably to exercise all or a portion of the within Unit Purchase Option and to purchase      Units
of IMAC Holdings, Inc., and hereby makes payment of $      (at the rate of $      per Unit) in payment of the Exercise Price pursuant
thereto. Please issue the Shares and Warrants comprising the Units as to which this Unit Purchase Option is exercised in accordance
with the instructions given below.

 

or

 

The
undersigned hereby elects irrevocably to convert its right to purchaseUnits purchasable under the within Unit Purchase Option
by surrender of the unexercised portion of the attached Unit Purchase Option (with a “Value” based of $      based on
a “Market Price” of $      ). Please issue the securities comprising the Units as to which this Unit Purchase Option
is exercised in accordance with the instructions given below.

 

	 	 
	 	Signature
	 	 
	 	 

 

INSTRUCTIONS
FOR REGISTRATION OF SECURITIES

 

	Name:		 
	 	(Print
    in Block Letters)	 
	 	 	 
	Address:		 

 

NOTICE:
THE SIGNATURE TO THIS FORM MUST CORRESPOND WITH THE NAME AS WRITTEN UPON THE FACE OF THE WITHIN UNIT PURCHASE OPTION IN EVERY
PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, AND MUST BE GUARANTEED BY A BANK, OTHER THAN A SAVINGS
BANK, OR BY A TRUST COMPANY OR BY A FIRM HAVING MEMBERSHIP ON A REGISTERED NATIONAL SECURITIES EXCHANGE.

 

    	 

    	 

    

 

Form
To Be Used To Assign Unit Purchase Option

 

ASSIGNMENT

 

(To
be executed by the registered Holder to effect a transfer of the within Unit Purchase Option)

 

FOR
VALUE RECEIVED, does hereby sell, assign and transfer unto the right to purchase Units of IMAC Holdings, Inc., (the “Company”)
evidenced by the within Unit Purchase Option and does hereby authorize the Company to transfer such right on the books of the
Company.

 

Dated:     ,
20__

 

	 	 
	 	Signature
	 	 
	 	 

 

NOTICE:
THE SIGNATURE TO THIS FORM MUST CORRESPOND WITH THE NAME AS WRITTEN UPON THE FACE OF THE WITHIN UNIT PURCHASE OPTION IN EVERY
PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, AND MUST BE GUARANTEED BY A BANK, OTHER THAN A SAVINGS
BANK, OR BY A TRUST COMPANY OR BY A FIRM HAVING MEMBERSHIP ON A REGISTERED NATIONAL SECURITIES EXCHANGE.

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