Document:

Exhibit
10.3

 

AEGIS
CAPITAL CORP.

 

December
7, 2022

 

PERSONAL
AND CONFIDENTIAL

 

Bruush
Oral Care Inc.

128
West Hastings Street, Unit 210

Vancouver,
British Columbia V6B 1G8

 

Attention:
Mr. Aneil Singh Manhas, Chief Executive Officer

 

Re: BRSH
Placement Agent Agreement

 

Ladies
and Gentlemen:

 

The
purpose of this placement agent agreement (this “Agreement”) is to set forth our agreement pursuant to which
Aegis Capital Corp. (“Aegis”) will act as the lead placement agent on a best efforts basis in connection
with the proposed private placement (the “Placement”) by Bruush Oral Care Inc. of its securities (the “Securities”).
This Agreement sets forth certain conditions and assumptions upon which the Placement is premised. The Company confirms that entry into
this Agreement and completion of the Placement with Aegis will not breach or otherwise violate the Company’s obligations to any
other investment bank.

 

The
terms of our agreement are as follows:

 

1. Engagement.
The Company hereby engages Aegis, for the period beginning on the date hereof and ending two (2) months thereafter or upon the
completion of the Placement (the “Closing”), whichever is sooner (the “Engagement
Period”), to act as the Company’s lead placement agent and investment banker in connection with the proposed
Placement. During the Engagement Period or until the consummation of the Placement, and as long as Aegis is proceeding in good faith
with preparations for the Placement, the Company agrees not to solicit, negotiate with or enter into any agreement with any other
source of financing (whether equity, debt or otherwise), any underwriter, potential underwriter, placement agent, financial advisor,
investment banking firm or any other person or entity in connection with an offering of the Company’s debt or equity
securities or any other financing by the Company.

 

2. The
Placement. The Placement is expected to consist of a sale of up to $5.0 million of shares of the Company’s common
stock, no par value per share (“Common Stock”) and/or pre-funded warrants to purchase Common Stock and investor warrants
to purchase Common Stock. The pricing and terms of the Placement will be mutually agreed upon by the Company and the investors
thereto. Aegis will act as the lead placement agent for the Placement subject to, among other matters referred to herein and
additional customary conditions, completion of Aegis’s due diligence examination of the Company and its affiliates, listing
approval by The Nasdaq Stock Exchange LLC (the “Exchange”) of the Securities to be issued, and the
execution of definitive transaction documents between the Company and investors in connection with the Placement (the
“Transaction Documents”). The actual size of the Placement, the precise number of Securities to be offered
by the Company and the offering price will be the subject of continuing negotiations between the Company and investors
thereto.

 

810
Seventh Avenue, 18th floor, New York, New York 10019 (212) 813-1010/Fax (212) 813-1047

Member
FINRA, SIPC

 

    	 

     

    

 

 

3. Placement
Compensation. The placement agent commission will be 10.0% for the Placement of any Securities sold at closing and 10.0% of
the proceeds from the exercise of any warrants, payable on exercise, and a non-accountable expense allowance equal to 3.0% of the
Placement.

 

4. Registration
Statement. If the Company decides to proceed with the Placement, the Company will, as soon as practicable after Closing of
the Placement but not later than fifteen (15) days following closing of the Placement, prepare and file with the Securities and
Exchange Commission (the “Commission”) a Registration Statement on Form F-1 (the “Registration
Statement”) under the Securities Act of 1933, as amended (the “Securities Act”) containing a
prospectus (the “Prospectus”) covering the resale of the Securities offered and sold in the Placement,
which Registration Statement shall be declared effective no more than fifteen (15) days after filing if it is not reviewed by the
Commission or not more than forty-five (45) days after filing if it is reviewed by the Commission. The Company will enter into a
registration rights agreement with the investors in the Placement setting forth the right of the investors to require the Company to
register the securities issued in the Placement. The Registration Statement (including the Prospectus therein), and all amendments
and supplements thereto, will be in form reasonably satisfactory to Aegis, counsel to Aegis and investors in the Placement. Other
than any information provided by Aegis or the investors in writing specifically for inclusion in the Registration Statement or the
Prospectus, the Company will be solely responsible for the contents of its Registration Statement and Prospectus and any and all
other written or oral communications provided by or on behalf of the Company to any actual or prospective investor of the
Securities, and the Company represents and warrants that such materials and such other communications will not, as of the date of
each filing of the Registration Statement and any amendments or as of the date of effectiveness, contain any untrue statement of a
material fact or omit to state a material fact required to be stated therein or necessary in order to make the statements therein,
in light of the circumstances under which they were made, not misleading. If at any time prior to the completion of the resale of
the Securities by the investors an event occurs that would cause the Registration Statement to contain an untrue statement of a
material fact or to omit to state a material fact necessary in order to make the statements therein not misleading or Prospectus (as
supplemented or amended) to contain an untrue statement of a material fact or to omit to state a material fact necessary in order to
make the statements therein, in light of the circumstances under which they were made, not misleading, the Company will notify Aegis
and the investors immediately of such event and the Company shall prepare a supplement or amendment to the Registration Statement or
Prospectus that corrects such statement or omission.

 

5. Lock-Up
Agreements. The Transaction Documents will provide, among other items, that the Company’s directors, executive
officers, employees and shareholders holding at least five percent (5%) of the outstanding Common Stock will enter into customary
“lock-up” agreements in favor of Aegis for a period of ninety (90) days from the closing date of the Placement;
provided, however, that any sales by parties to the lock-up agreements shall be subject to the lock-up agreements and provided
further, that none of such shares of Common Stock shall be saleable in the public market until the expiration of the ninety (90) day
period described above and in compliance with applicable law..

 

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6. Company
Standstill. The Transaction Documents will provide, among other items, that the Company will agree, for a period of one
hundred eighty (180) days from the closing date of the Placement, that without the prior written consent of Aegis, it will not (a)
offer, sell, issue, or otherwise transfer or dispose of, directly or indirectly, any equity of the Company or any securities
convertible into or exercisable or exchangeable for equity of the Company; (b) file or caused to be filed any registration statement
with the Commission relating to the offering of any equity of the Company or any securities convertible into or exercisable or
exchangeable for equity of the Company; or (c) enter into any agreement or announce the intention to effect any of the actions
described in subsections (a) or (b) hereof (all of such matters, the “Standstill”). So long none of such
equity securities shall be saleable in the public market until the expiration of the period described above, the following matters
shall not be prohibited by the Standstill: (i) the adoption of an equity incentive plan and the grant of awards or equity pursuant
to any equity incentive plan, and the filing of a registration statement on Form S-8 or any other form prescribed by the Commission
therefor applicable for foreign private issuers; and (ii) the issuance of equity securities in connection with an acquisition or a
strategic relationship, which may include the sale of equity securities. In no event should any equity transaction during the
Standstill period result in the sale of equity at an offering price to the public less than that of the Placement referred herein.
In addition to being entitled to exercise all rights provided herein or granted by law, including recovery of damages, Aegis and the
Company will be entitled to seek specific performance if a breach or a threatened breach by the Company under this Section 6
occurs.

 

7. Expenses.
The Company will be responsible for and will pay all expenses relating to the Placement, including, without limitation, (a) all
filing fees and expenses relating to the registration of the Securities with the Commission; (b) all FINRA filing fees; (c) all fees
and expenses relating to the listing of the Company’s equity or equity-linked securities on the Exchange; (d) all fees,
expenses and disbursements relating to the registration or qualification of the Securities under the “blue sky”
securities laws of such states and other jurisdictions as Aegis may reasonably designate (including, without limitation, all filing
and registration fees, and the reasonable fees and disbursements of the Company’s “blue sky” counsel, which will
be Aegis’s counsel) unless such filings are not required in connection with the listing of the securities issued in the
Placement on the Exchange; (e) all fees, expenses and disbursements relating to the registration, qualification or exemption of the
securities issued in the Placement under the securities laws of such foreign jurisdictions as Aegis may reasonably designate; (f)
the costs of all mailing and printing of the Placement documents; (g) transfer and/or stamp taxes, if any, payable upon the transfer
of Securities from the Company to Aegis; (h) the fees and expenses of the Company’s accountants; (i) such fees of legal
counsel of the investors in the Placement as may be agreed between the Company and such investors; (j) $100,000 for reasonable legal
fees and disbursements for Aegis’s counsel; and (k) $7,500 for reasonable legal expenses of investor counsel.

 

8. Right
of First Refusal. If, for the period beginning on the closing date of the Placement and ending two (2) years after the
closing date of the Placement, the Company or any of its subsidiaries (a) decides to finance or refinance any indebtedness, Aegis
(or any affiliate designated by Aegis) shall have the right to act as sole book-runner, sole manager, sole placement agent or sole
agent with respect to such financing or refinancing; or (b) decides to raise funds by means of a public offering (including
at-the-market facility) or a private placement or any other capital raising financing of equity, equity-linked or debt securities,
Aegis (or any affiliate designated by Aegis) shall have the right to act as sole book-running manager, sole underwriter or sole
placement agent for such financing. If Aegis or one of its affiliates decides to accept any such engagement, the agreement governing
such engagement (each, a “Subsequent Transaction Agreement”) will contain, among other things, provisions for customary
fees for transactions of similar size and nature, but in no event will the fees be less than those outlined herein, and the
provisions of this Agreement, including indemnification, which are appropriate to such a transaction. Notwithstanding the foregoing,
the decision to accept the Company’s engagement under this Section 8 shall be made by Aegis or one of its affiliates, by a
written notice to the Company, within ten (10) days of the receipt of the Company’s notification of its financing
needs.

 

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9. Tail
Financing. Aegis shall be entitled to compensation under Section 3 herein, calculated in the manner set forth therein, with
respect to any public or private offering or other financing or capital raising transaction of any kind (“Tail
Financing”) to the extent that such financing or capital is provided to the Company by funds whom Aegis had contacted
during the Engagement Period or introduced to the Company during the Engagement Period, if such Tail Financing is consummated at any
time within the twelve (12) month period following the expiration or termination of this Agreement.

 

10. Termination. Notwithstanding
anything to the contrary contained herein, the Company agrees that the provisions relating to the payment of fees, reimbursement of
expenses, right of first refusal, indemnification and contribution, confidentiality, conflicts, independent contractor and waiver of
the right to trial by jury will survive any termination or expiration of this Agreement. During the engagement hereunder: (i) the
Company will not, and will not permit its representatives to, other than in coordination with Aegis, contact or solicit
institutions, corporations or other entities or individuals as potential purchasers of the Securities and (ii) the Company will not
pursue any financing transaction which would be in lieu of a Placement. Furthermore, the Company agrees that during Aegis’s
engagement hereunder, all inquiries from prospective investors will be referred to Aegis. 

 

11. Publicity.
The Company agrees that it will not issue press releases or engage in any other publicity, without Aegis’s prior written
consent, commencing on the date hereof and continuing until the final closing of the Placement.

 

12. Information.
During the Engagement Period or until the Closing, the Company agrees to cooperate with Aegis and to furnish, or cause to be
furnished, to Aegis, any and all information and data concerning the Company, and the Placement that Aegis deems appropriate (the
“Information”). The Company will provide Aegis reasonable access during normal business hours from and
after the date of execution of this Agreement until the date of the Closing to all of the Company’s assets, properties, books,
contracts, commitments and records and to the Company’s officers, directors, employees, appraisers, independent accountants,
legal counsel and other consultants and advisors. Except as contemplated by the terms hereof or as required by applicable law, Aegis
will keep strictly confidential all non-public Information concerning the Company provided to Aegis. No obligation of
confidentiality will apply to Information that: (a) is in the public domain as of the date hereof or hereafter enters the public
domain without a breach by Aegis, (b) was known or became known by Aegis prior to the Company’s disclosure thereof to Aegis as
demonstrated by the existence of its written records, (c) becomes known to Aegis from a source other than the Company which
information is not provided by the breach of an obligation of confidentiality owed to the Company, (d) is disclosed by the
Company to a third party without restrictions on its disclosure or (e) is independently developed by Aegis as demonstrated by its
written records. For the avoidance of doubt, except as otherwise provided herein, all information which is not publicly available
relating to the Company’s proprietary technology is proprietary and confidential.

 

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13. No
Third Party Beneficiaries; No Fiduciary Obligations. This Agreement does not create, and shall not be construed as creating,
rights enforceable by any person or entity not a party hereto, except those entitled hereto by virtue of the indemnification
provisions hereof. The Company acknowledges and agrees that: (i) Aegis is not and shall not be construed as a fiduciary of the
Company and shall have no duties or liabilities to the equity holders or the creditors of the Company or any other person by virtue
of this Agreement or the retention of Aegis hereunder, all of which are hereby expressly waived; and (ii) Aegis is a full service
securities firm engaged in a wide range of businesses and from time to time, in the ordinary course of its business, Aegis or its
affiliates may hold long or short positions and trade or otherwise effect transactions for its own account or the account of its
customers in debt or equity securities or loans of the companies which may be the subject of the transactions contemplated by this
Agreement. During the course of Aegis’s engagement with the Company, Aegis may have in its possession material, non-public
information regarding other companies that could potentially be relevant to the Company or the transactions contemplated herein but
which cannot be shared due to an obligation of confidence to such other companies.

 

14. Indemnification,
Advancement & Contribution.

 

(a) Indemnification.
The Company agrees to indemnify and hold harmless Aegis, its affiliates and each person controlling Aegis (within the meaning of
Section 15 of the Securities Act), and the directors, officers, agents and employees of Aegis, its affiliates and each such
controlling person (Aegis, and each such entity or person hereafter is referred to as an “Indemnified
Person”) from and against any losses, claims, damages, judgments, assessments, costs and other liabilities
(collectively, the “Liabilities”), and shall reimburse each Indemnified Person for all fees and expenses
(including the reasonable fees and expenses of counsel for the Indemnified Persons) (collectively, the
“Expenses”) and agrees to advance payment of such Expenses as they are incurred by an Indemnified Person
in investigating, preparing, pursuing or defending any actions, whether or not any Indemnified Person is a party thereto, arising
out of or based upon (i) any untrue statement or alleged untrue statement of a material fact contained in (A) the Registration
Statement, Prospectus or any other transaction documents in connection with the Placement (as from time to time each may be amended
and supplemented), (B) any materials or information provided to investors by, or with the approval of, the Company in connection
with the marketing of the Placement, including any “road show” or investor presentations made to investors by the
Company (whether in person or electronically), or (C) any application or other document or written communication (collectively
called “application”) executed by the Company or based upon written information furnished by the Company in any
jurisdiction in order to qualify the Securities under the securities laws thereof or to file for an exemption from such requirement
or filed with the Commission, any state securities commission or agency, any national securities exchange; or (ii) the omission or
alleged omission therefrom of a material fact required to be stated therein or necessary to make the statements therein, in the
light of the circumstances under which they were made, not misleading, unless such statement or omission was made in reliance upon,
and in conformity with, information provided to the Company by Aegis in writing specifically for use in the Registration Statement,
Prospectus or any other placement documents with respect which or resulting from conduct by Aegis or another Indemnified Party, as
to which Aegis shall indemnify and hold harmless the Company, its officers, directors and controlling parties in the manner set
forth in this Section 14. The Company also agrees to reimburse and advance each Indemnified Person for all Expenses as they are
incurred in connection with such Indemnified Person’s enforcement of his or its rights under this Section 14. 

 

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(b) Procedure.
Upon receipt by an Indemnified Person of actual notice of an action against such Indemnified Person with respect to which indemnity
may reasonably be expected to be sought under this Section 14, such Indemnified Person shall promptly notify the Company in writing;
provided that failure by any Indemnified Person so to notify the Company shall not relieve the Company from any obligation or
liability which the Company may have on account of this Section 14 or otherwise to such Indemnified Person. The Company shall, if
requested by Aegis, assume the defense of any such action (including the employment of counsel designated by Aegis and reasonably
satisfactory to the Company). Any Indemnified Person shall have the right to employ separate counsel in any such action and
participate in the defense thereof, but the fees and expenses of such counsel shall be at the expense of such Indemnified Person
unless: (i) the Company has failed promptly to assume the defense and employ separate counsel reasonably acceptable to Aegis for the
benefit of Aegis and the other Indemnified Persons or (ii) such Indemnified Person shall have been advised that in the opinion of
counsel that there is an actual or potential conflict of interest that prevents (or makes it imprudent for) the counsel designated
by and engaged by the Company for the purpose of representing the Indemnified Person, to represent both such Indemnified Person and
any other person represented or proposed to be represented by such counsel, in which event the Company shall pay the reasonable fees
and expenses of one counsel, plus local counsel, for all Indemnified Parties, which counsel shall, if Aegis is a defendant, be
designated by Aegis. The Company shall not be liable for any settlement of any action effected without its written consent (which
shall not be unreasonably withheld). In addition, the Company shall not, without the prior written consent of Aegis, settle,
compromise or consent to the entry of any judgment in or otherwise seek to terminate any pending or threatened action in respect of
which advancement, reimbursement, indemnification or contribution may be sought hereunder (whether or not such Indemnified Person is
a party thereto) unless such settlement, compromise, consent or termination (i) includes an unconditional release of each
Indemnified Person, acceptable to such Indemnified Party, from all Liabilities arising out of such action for which indemnification
or contribution may be sought hereunder and (ii) does not include a statement as to or an admission of fault, culpability or a
failure to act, by or on behalf of any Indemnified Person. The advancement, reimbursement, indemnification and contribution
obligations of the Company required hereby shall be made by periodic payments of the amount thereof during the course of the
investigation or defense, as every Liability and Expense is incurred and is due and payable, and in such amounts as fully satisfy
each and every Liability and Expense as it is incurred (and in no event later than 30 days following the date of any invoice
therefore).

 

(c) Contribution.
In the event that a court of competent jurisdiction makes a finding, final beyond right of review, that indemnity is unavailable to
an Indemnified Person, the Company shall contribute to the Liabilities and Expenses paid or payable by such Indemnified Person in
such proportion as is appropriate to reflect (i) the relative benefits to the Company, on the one hand, and to Aegis and any other
Indemnified Person, on the other hand, of the matters contemplated by this Section 1414 or (ii) if the allocation provided by the
immediately preceding clause is not permitted by applicable law, not only such relative benefits but also the relative fault of the
Company, on the one hand, and Aegis and any other Indemnified Person, on the other hand, in connection with the matters as to which
such Liabilities or Expenses relate, as well as any other relevant equitable considerations; provided that in no event shall the
Company contribute less than the amount necessary to ensure that all Indemnified Persons, in the aggregate, are not liable for any
Liabilities and Expenses in excess of the amount of commissions and non-accountable expense allowance actually received by Aegis in
the Placement. The relative fault shall be determined by reference to, among other things, whether the untrue or alleged untrue
statement of a material fact or the omission or alleged omission to state a material fact relates to information supplied by the
Company on the one hand or Aegis on the other and the parties’ relative intent, knowledge, access to information and
opportunity to correct or prevent such statement or omission. The Company and Aegis agree that it would not be just and equitable if
contributions pursuant to this subsection 14(c) were determined by pro rata allocation or by any other method of allocation which
does not take account of the equitable considerations referred to above in this subsection 14(c). For purposes of this paragraph,
the relative benefits to the Company, on the one hand, and to Aegis on the other hand, of the matters contemplated by this Section
14 shall be deemed to be in the same proportion as: (a) the total value received by the Company in the Placement, whether or not
such Placement is consummated, bears to (b) the commissions paid to Aegis under the Transaction Documents. Notwithstanding the
above, no person guilty of fraudulent misrepresentation within the meaning of Section 11(f) of the Securities Act shall be entitled
to contribution from a party who was not guilty of fraudulent misrepresentation.

 

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(d) Limitation.
The Company also agrees that no Indemnified Person shall have any liability (whether direct or indirect, in contract or tort or
otherwise) to the Company for or in connection with advice or services rendered or to be rendered by any Indemnified Person pursuant
to this Agreement, the transactions contemplated thereby or any Indemnified Person’s actions or inactions in connection with
any such advice, services or transactions, except to the extent that a court of competent jurisdiction has made a finding that
Liabilities (and related Expenses) of the Company have resulted exclusively from such Indemnified Person’s gross negligence or
willful misconduct in connection with any such advice, actions, inactions or services.

 

15. Governing
Law; Venue. This Agreement shall be governed by and construed in accordance with the law of the State of New York. Each of
Aegis and the Company (i) agrees that any legal suit, action or proceeding arising out of or relating to this Agreement and/or the
transactions contemplated hereby will be instituted exclusively in the courts of the State of New York located in the City and
County of New York or in the United States District Court for the Southern District of New York (ii) waives any objection which it
may have or hereafter to the venue of any such suit, action or proceeding, and (iii) irrevocably consents to the jurisdiction of
such courts in any such suit, action or proceeding. Each of Aegis and the Company further agrees to accept and acknowledge service
of any and all process which may be served in any such suit, action or proceeding in such courts and agrees that service of process
upon the Company mailed by certified mail to the Company’s address will be deemed in every respect effective service of
process upon the Company, in any such suit, action or proceeding, and service of process upon Aegis mailed by certified mail to
Aegis’s address will be deemed in every respect effective service process upon Aegis, in any such suit, action or proceeding.
Notwithstanding any provision of this Agreement to the contrary, the Company agrees that neither Aegis nor its affiliates, and the
respective officers, directors, employees, agents and representatives of Aegis, its affiliates and each other person, if any,
controlling Aegis or any of its affiliates, will have any liability (whether direct or indirect, in contract or tort or otherwise)
to the Company for or in connection with the engagement and transaction described herein except for any such liability for losses,
claims, damages or liabilities incurred by the Company that are finally judicially determined to have resulted from the bad
faith or gross negligence of such individuals or entities. Aegis will act under this Agreement as an independent contractor with
duties to the Company.

 

16. Equitable
Remedies. The parties agree that monetary damages may not be adequate compensation for any loss incurred by reason of any
breach or threatened breach by the Company of its obligations contained in Section 6 or Section 8 of the Agreement. If a breach or a
threatened breach by the Company of any such obligations occurs, Aegis will, in addition to any and all other rights and remedies
that may be available to such party at law, at equity, or otherwise in respect of such breach, be entitled to seek equitable relief,
including a temporary restraining order, an injunction, specific performance of the terms of Section 6 and Section 8, as applicable,
and any other relief that may be available from a court of competent jurisdiction.

 

If
you are in agreement with the foregoing, please sign and return to us one copy of this Agreement. This Agreement may be executed in counterparts
(including facsimile or .pdf counterparts), each of which shall be deemed an original but all of which together shall constitute one
and the same instrument.

 

[Signature
Page of BRSH Placement Agent Agreement Follows]

 

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	 	Very truly yours,
	 	 	 
	 	Aegis Capital Corp. 
	 	 	 
	 	By:	
	 	Name:	Robert
    Eide
	 	Title:	Chief
    Executive Officer

 

AGREED
AND ACCEPTED:

 

The
foregoing accurately sets forth our understanding and agreement with respect to the matters set forth herein.

 

Bruush
Oral Care Inc.

 

	By:		 
	Name:	Aneil
    Singh Manhas	 
	Title:	Chief
    Executive Officer	 

 

[Signature
Page of BRSH Placement Agent Agreement]

 

    	8Exhibit
10.4

 

NEITHER
THIS SECURITY NOR THE SECURITIES FOR WHICH THIS SECURITY IS EXERCISABLE HAVE BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION
OR THE SECURITIES COMMISSION OF ANY STATE IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED
(THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT
UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS
OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS. THIS SECURITY AND THE SECURITIES ISSUABLE UPON EXERCISE
OF THIS SECURITY MAY BE PLEDGED IN CONNECTION WITH A BONA FIDE MARGIN ACCOUNT OR OTHER LOAN SECURED BY SUCH SECURITIES.

 

PRE-FUNDED
COMMON STOCK PURCHASE WARRANT

 

BRUUSH
ORAL CARE INC.

 

	Warrant
    Shares: _______	Initial
    Exercise Date: December __, 2022

 

THIS
PRE-FUNDED COMMON STOCK PURCHASE WARRANT (the “Warrant”) certifies that, for value received, _____________ or its
assigns (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 the date hereof (the “Initial Exercise Date”) and until this Warrant is exercised
in full (the “Termination Date”) but not thereafter, to subscribe for and purchase from BRUUSH ORAL CARE INC., a corporation
incorporated under the law of the Province of British Columbia, Canada (the “Company”), up to ______ shares (as subject
to adjustment hereunder, the “Warrant Shares”) of the Company’s Common Stock. The purchase price of one share
of Common Stock under this Warrant shall be equal to the Exercise Price, as defined in Section 2(b).

 

Section
1. Definitions. Capitalized terms used and not otherwise defined herein shall have the meanings set forth in that certain
Securities Purchase Agreement (the “Purchase Agreement”), dated December 7, 2022, among the Company and the purchasers
signatory thereto.

 

Section
2. Exercise.

 

a) Exercise
of Warrant. Subject to the provisions of Section 2(e) herein, exercise of the purchase rights represented by this Warrant may be
made, in whole or in part, at any time or times on or after the Initial Exercise Date and on or before the Termination Date by
delivery to the Company of a duly executed PDF copy submitted by e-mail (or e-mail attachment) of the Notice of Exercise
substantially in the form annexed hereto as Exhibit A (the “Notice of Exercise”). Within the earlier of (i) two
(2) Trading Days and (ii) the number of Trading Days comprising the Standard Settlement Period (as defined in Section 2(d)(i)
herein) following the date of exercise as aforesaid, the Holder shall deliver the aggregate Exercise Price for the Warrant Shares
specified in the applicable Notice of Exercise by wire transfer of immediately available funds or cashier’s check drawn on a
United States bank unless the cashless exercise procedure specified in Section 2(c) below is specified in the applicable Notice of
Exercise. No ink-original Notice of Exercise shall be required, nor shall any medallion guarantee (or other type of guarantee or
notarization) of any Notice of Exercise be required. Notwithstanding anything herein to the contrary, the Holder shall not be
required to physically surrender this Warrant to the Company until the Holder has purchased all of the Warrant Shares available
hereunder and the Warrant has been exercised in full, in which case, the Holder shall surrender this Warrant to the Company for
cancellation within three (3) Trading Days of the date on which the final Notice of Exercise is delivered to the Company. Partial
exercises of this Warrant resulting in purchases of a portion of the total number of Warrant Shares available hereunder shall have
the effect of lowering the outstanding number of Warrant Shares purchasable hereunder in an amount equal to the applicable number of
Warrant Shares purchased. The Holder and the Company shall maintain records showing the number of Warrant Shares purchased and the
date of such purchases. The Company shall deliver any objection to any Notice of Exercise within one (1) Trading Day of receipt of
such notice. The Holder and any assignee, by acceptance of this Warrant, acknowledge and agree that, by reason of the
provisions of this paragraph, following the purchase of a portion of the Warrant Shares hereunder, the number of Warrant Shares
available for purchase hereunder at any given time may be less than the amount stated on the face hereof.

 

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b) Exercise
Price. The aggregate exercise price of this Warrant, except for a nominal exercise price of $0.001 per Warrant Share, was pre-funded
to the Company on or prior to the Initial Exercise Date and, consequently, no additional consideration (other than the nominal exercise
price of $0.001 per Warrant Share) shall be required to be paid by the Holder to any Person to effect any exercise of this Warrant. The
Holder shall not be entitled to the return or refund of all, or any portion, of such pre-paid aggregate exercise price under any circumstance
or for any reason whatsoever. The remaining unpaid exercise price per share of Common Stock under this Warrant shall be $0.001, subject
to adjustment hereunder (the “Exercise Price”).

 

c) Cashless
Exercise. This Warrant may also be exercised, in whole or in part, at such time by means of a “cashless exercise” in
which the Holder shall be entitled to receive a number of Warrant Shares equal to the quotient obtained by dividing [(A-B) (X)] by (A),
where:

 

	 	(A)	=
    as applicable: (i) the VWAP on the Trading Day immediately preceding the date of the applicable Notice of Exercise if such Notice
    of Exercise is (1) both executed and delivered pursuant to Section 2(a) hereof on a day that is not a Trading Day or (2) both executed
    and delivered pursuant to Section 2(a) hereof on a Trading Day prior to the opening of “regular trading hours” (as defined
    in Rule 600(b) of Regulation NMS promulgated under the federal securities laws) on such Trading Day, (ii) at the option of the Holder
    either (y) the VWAP on the Trading Day immediately preceding the date of the applicable Notice of Exercise or (z) the Bid Price of
    the Common Stock on the principal Trading Market as reported by Bloomberg L.P. as of the time of the Holder’s execution of
    the applicable Notice of Exercise if such Notice of Exercise is executed during “regular trading hours” on a Trading
    Day and is delivered within two (2) hours thereafter (including until two (2) hours after the close of “regular trading hours”
    on a Trading Day) pursuant to Section 2(a) hereof or (iii) the VWAP on the date of the applicable Notice of Exercise if the date
    of such Notice of Exercise is a Trading Day and such Notice of Exercise is both executed and delivered pursuant to Section 2(a) hereof
    after the close of “regular trading hours” on such Trading Day;

 

    	2

    	 

    

 

	 	(B)	=
    the Exercise Price of this Warrant, as adjusted hereunder; and
	 	 	 
	 	(X)	=
    the number of Warrant Shares that would be issuable upon exercise of this Warrant in accordance with the terms of this Warrant if
    such exercise were by means of a cash exercise rather than a cashless exercise.

 

“Bid
Price” means, for any date, the price determined by the first of the following clauses that applies: (a) if the Common Stock
is then listed or quoted on a Trading Market, the bid price of the Common Stock for the time in question (or the nearest preceding date)
on the Trading Market on which the Common Stock is then listed or quoted as reported by Bloomberg L.P. (based on a Trading Day from 9:30
a.m. (New York City time) to 4:02 p.m. (New York City time)), (b) if OTCQB or OTCQX is not a Trading Market, the volume weighted average
price of the Common Stock for such date (or the nearest preceding date) on OTCQB or OTCQX as applicable, (c) if the Common Stock is not
then listed or quoted for trading on OTCQB or OTCQX and if prices for the Common Stock are then reported on The Pink Open Market (or
a similar organization or agency succeeding to its functions of reporting prices), the most recent bid price per share of the Common
Stock so reported, or (d) in all other cases, the fair market value of a share of Common Stock as determined by an independent appraiser
selected in good faith by the Holders of a majority in interest of the Securities then outstanding and reasonably acceptable to the Company,
the fees and expenses of which shall be paid by the Company.

 

“VWAP” means,
for any date, the price determined by the first of the following clauses that applies: (a) if the Common Stock is then listed or quoted
on a Trading Market, the daily volume weighted average price of the Common Stock for such date (or the nearest preceding date) on the
Trading Market on which the Common Stock is then listed or quoted as reported by Bloomberg L.P. (based on a Trading Day from 9:30 a.m.
(New York City time) to 4:02 p.m. (New York City time)), (b) if OTCQB or OTCQX is not a Trading Market, the volume weighted average price
of the Common Stock for such date (or the nearest preceding date) on OTCQB or OTCQX as applicable, (c) if the Common Stock is not then
listed or quoted for trading on OTCQB or OTCQX and if prices for the Common Stock are then reported on The Pink Open Market (or a similar
organization or agency succeeding to its functions of reporting prices), the most recent bid price per share of the Common Stock so reported,
or (d) in all other cases, the fair market value of a share of Common Stock as determined by an independent appraiser selected in good
faith by the Holders of a majority in interest of the Securities then outstanding and reasonably acceptable to the Company, the fees
and expenses of which shall be paid by the Company.

 

If
Warrant Shares are issued in such a cashless exercise, the parties acknowledge and agree that in accordance with Section 3(a)(9) of the
Securities Act, the Warrant Shares shall take on the characteristics of the Warrants being exercised, and the holding period of the Warrant
Shares being issued may be tacked on to the holding period of this Warrant. Without limiting any other provision in the Transaction Documents,
assuming (i) the Holder is not an Affiliate of the Company, and (ii) all of the applicable conditions of Rule 144 promulgated under the
Securities Act with respect to Holder and the Warrant Shares are met in the case of such a cashless exercise, the Company agrees that
the Company will cause the removal of the legend from such Warrant Shares (including by delivering an opinion of the Company’s
counsel to the Company’s transfer agent at its own expense to ensure the foregoing), and the Company agrees that the Holder is
under no obligation to sell the Warrant Shares issuable upon the exercise of the Warrant prior to removing the legend. The Company agrees
not to take any position contrary to this Section 2(c).

 

    	3

    	 

    

 

d) Mechanics
of Exercise.

 

i. Delivery
of Warrant Shares Upon Exercise. The Company shall cause the Warrant Shares purchased hereunder to be transmitted by the Transfer
Agent to the Holder by crediting the account of the Holder’s or its designee’s balance account with The Depository Trust
Company through its Deposit or Withdrawal at Custodian system (“DWAC”) if the Company is then a participant in such
system and either (A) there is an effective registration statement permitting the issuance of the Warrant Shares to or resale of the
Warrant Shares by the Holder or (B) the Warrant Shares are eligible for resale by the Holder without volume or manner-of-sale limitations
pursuant to Rule 144 (assuming cashless exercise of the Warrants), and otherwise by physical delivery of a certificate, registered in
the Company’s share register in the name of the Holder or its designee, for the number of Warrant Shares to which the Holder is
entitled pursuant to such exercise to the address specified by the Holder in the Notice of Exercise by the date that is the earliest
of (i) two (2) Trading Days after the delivery to the Company of the Notice of Exercise, (ii) one (1) Trading Day after delivery of the
aggregate Exercise Price to the Company and (iii) the number of Trading Days comprising the Standard Settlement Period after the delivery
to the Company of the Notice of Exercise (such date, the “Warrant Share Delivery Date”). Upon delivery of the Notice
of Exercise, the Holder shall be deemed for all corporate purposes to have become the holder of record of the Warrant Shares with respect
to which this Warrant has been exercised, irrespective of the date of delivery of the Warrant Shares, provided that payment of the aggregate
Exercise Price (other than in the case of a cashless exercise) is received within the earlier of (i) two (2) Trading Days and (ii) the
number of Trading Days comprising the Standard Settlement Period following delivery of the Notice of Exercise. If the Company fails for
any reason to deliver to the Holder the Warrant Shares subject to a Notice of Exercise by the Warrant Share Delivery Date, the Company
shall pay to the Holder, in cash, as liquidated damages and not as a penalty, for each $1,000 of Warrant Shares subject to such exercise
(based on the VWAP of the Common Stock on the date of the applicable Notice of Exercise), $10 per Trading Day (increasing to $20 per
Trading Day on the third (3rd) Trading Day after the Warrant Share Delivery Date) for each Trading Day after such Warrant Share Delivery
Date until such Warrant Shares are delivered or Holder rescinds such exercise. The Company agrees to maintain a transfer agent that is
a participant in the FAST program so long as this Warrant remains outstanding and exercisable. As used herein, “Standard Settlement
Period” means the standard settlement period, expressed in a number of Trading Days, on the Company’s primary Trading
Market with respect to the Common Stock as in effect on the date of delivery of the Notice of Exercise.

 

    	4

    	 

    

 

ii. Delivery
of New Warrants Upon Exercise. If this Warrant shall have been exercised in part, the Company shall, at the request of a Holder and
upon surrender of this Warrant certificate, at the time of delivery of the Warrant Shares, deliver to the Holder a new Warrant evidencing
the rights of the 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. 

 

iii. Rescission
Rights. If the Company fails to cause the Transfer Agent to transmit to the Holder the Warrant Shares pursuant to Section 2(d)(i)
by the Warrant Share Delivery Date, then the Holder will have the right to rescind such exercise.

 

iv. Compensation
for Buy-In on Failure to Timely Deliver Warrant Shares Upon Exercise. In addition to any other rights available to the Holder, if
the Company fails to cause the Transfer Agent to transmit to the Holder the Warrant Shares in accordance with the provisions of Section
2(d)(i) above pursuant to an exercise on or before the Warrant Share Delivery Date, and if after such date the Holder is required by
its broker to purchase (in an open market transaction or otherwise) or the Holder’s brokerage firm otherwise purchases, shares
of Common Stock to deliver in satisfaction of a sale by the Holder of the Warrant Shares which the Holder anticipated receiving upon
such exercise (a “Buy-In”), then the Company shall (A) pay in cash to the Holder the amount, if any, by which (x)
the Holder’s total purchase price (including brokerage commissions, if any) for the shares of Common Stock so purchased exceeds
(y) the amount obtained by multiplying (1) the number of Warrant Shares that the Company was required to deliver to the Holder in connection
with the exercise at issue times (2) the price at which the sell order giving rise to such purchase obligation was executed, and (B)
at the option of the Holder, either reinstate the portion of the Warrant and equivalent number of Warrant Shares for which such exercise
was not honored (in which case such exercise shall be deemed rescinded) or deliver to the Holder the number of shares of Common Stock
that would have been issued had the Company timely complied with its exercise and delivery obligations hereunder. For example, if the
Holder purchases Common Stock having a total purchase price of $11,000 to cover a Buy-In with respect to an attempted exercise of shares
of Common Stock with an aggregate sale price giving rise to such purchase obligation of $10,000, under clause (A) of the immediately
preceding sentence the Company shall be required to pay the Holder $1,000. The Holder shall provide the Company written notice indicating
the amounts payable to the Holder in respect of the Buy-In and, upon request of the Company, evidence of the amount of such loss. Nothing
herein shall limit a Holder’s right to pursue any other remedies available to it hereunder, at law or in equity including, without
limitation, a decree of specific performance and/or injunctive relief with respect to the Company’s failure to timely deliver shares
of Common Stock upon exercise of the Warrant as required pursuant to the terms hereof.

 

    	5

    	 

    

 

v. 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 the Holder would otherwise be entitled to purchase upon such exercise, the Company shall,
at its election, either pay a cash adjustment in respect of such final fraction in an amount equal to such fraction multiplied by the
Exercise Price or round up to the next whole share.

 

vi. Charges,
Taxes and Expenses. Issuance of 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 Warrant Shares, all of which taxes and expenses shall be paid by the Company, and
such Warrant Shares 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 that 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 as Exhibit B 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. The Company shall pay
all Transfer Agent fees required for same-day processing of any Notice of Exercise and all fees to the Depository Trust Company (or another
established clearing corporation performing similar functions) required for same-day electronic delivery of the Warrant Shares. 

 

vii. 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. 

 

    	6

    	 

    

 

e) Holder’s
Exercise Limitations. The Company shall not effect any exercise of this Warrant, and a Holder shall not have the right to exercise
any portion of this Warrant, pursuant to Section 2 or otherwise, to the extent that after giving effect to such issuance after exercise
as set forth on the applicable Notice of Exercise, the Holder (together with the Holder’s Affiliates, and any other Persons acting
as a group together with the Holder or any of the Holder’s Affiliates (such Persons, “Attribution Parties”)),
would beneficially own in excess of the Beneficial Ownership Limitation (as defined below). For purposes of the foregoing sentence, the
number of shares of Common Stock beneficially owned by the Holder and its Affiliates and Attribution Parties shall include the number
of shares of Common Stock issuable upon exercise of this Warrant with respect to which such determination is being made, but shall exclude
the number of shares of Common Stock which would be issuable upon (i) exercise of the remaining, unexercised portion of this Warrant
beneficially owned by the Holder or any of its Affiliates or Attribution Parties and (ii) exercise or conversion of the unexercised or
non-converted portion of any other securities of the Company (including, without limitation, any other Common Stock Equivalents) subject
to a limitation on conversion or exercise analogous to the limitation contained herein beneficially owned by the Holder or any of its
Affiliates or Attribution Parties. Except as set forth in the preceding sentence, for purposes of this Section 2(e), beneficial ownership
shall be calculated in accordance with Section 13(d) of the Exchange Act and the rules and regulations promulgated thereunder, it being
acknowledged by the Holder that the Company is not representing to the Holder that such calculation is in compliance with Section 13(d)
of the Exchange Act and the Holder is solely responsible for any schedules required to be filed in accordance therewith. To the extent
that the limitation contained in this Section 2(e) applies, the determination of whether this Warrant is exercisable (in relation to
other securities owned by the Holder together with any Affiliates and Attribution Parties) and of which portion of this Warrant is exercisable
shall be in the sole discretion of the Holder, and the submission of a Notice of Exercise shall be deemed to be the Holder’s determination
of whether this Warrant is exercisable (in relation to other securities owned by the Holder together with any Affiliates and Attribution
Parties) and of which portion of this Warrant is exercisable, in each case subject to the Beneficial Ownership Limitation, and the Company
shall have no obligation to verify or confirm the accuracy of such determination. In addition, a determination as to any group status
as contemplated above shall be determined in accordance with Section 13(d) of the Exchange Act and the rules and regulations promulgated
thereunder. For purposes of this Section 2(e), in determining the number of outstanding shares of Common Stock, a Holder may rely on
the number of outstanding shares of Common Stock as reflected in (A) the Company’s most recent annual report filed with the Commission,
as the case may be, (B) a more recent public announcement by the Company or (C) a more recent written notice by the Company or the Transfer
Agent setting forth the number of shares of Common Stock outstanding. Upon the written or oral request of a Holder, the Company shall
within one (1) Trading Day confirm orally and in writing to the Holder the number of shares of Common Stock then outstanding. In any
case, the number of outstanding shares of Common Stock shall be determined after giving effect to the conversion or exercise of securities
of the Company, including this Warrant, by the Holder or its Affiliates or Attribution Parties since the date as of which such number
of outstanding shares of Common Stock was reported. The “Beneficial Ownership Limitation” shall be [4.99%] [9.99%]
of the number of shares of the Common Stock outstanding immediately after giving effect to the issuance of shares of Common Stock issuable
upon exercise of this Warrant. The Holder, upon notice to the Company, may increase or decrease the Beneficial Ownership Limitation provisions
of this Section 2(e), provided that the Beneficial Ownership Limitation in no event exceeds 9.99% of the number of shares of the Common
Stock outstanding immediately after giving effect to the issuance of shares of Common Stock upon exercise of this Warrant held by the
Holder and the provisions of this Section 2(e) shall continue to apply. Any increase in the Beneficial Ownership Limitation will not
be effective until the 61st day after such notice is delivered to the Company. The provisions of this paragraph shall
be construed and implemented in a manner otherwise than in strict conformity with the terms of this Section 2(e) to correct this paragraph
(or any portion hereof) which may be defective or inconsistent with the intended Beneficial Ownership Limitation herein contained or
to make changes or supplements necessary or desirable to properly give effect to such limitation. The limitations contained in this paragraph
shall apply to a successor holder of this Warrant.

 

    	7

    	 

    

 

Section
3. Certain Adjustments.

 

a) Stock
Dividends and Splits. If the Company, at any time while this Warrant is outstanding: (i) pays a stock dividend or otherwise makes
a distribution or distributions on shares of its Common Stock or any other equity or equity equivalent securities payable in shares of
Common Stock (which, for avoidance of doubt, shall not include any shares of Common Stock issued by the Company upon exercise of this
Warrant), (ii) subdivides outstanding shares of Common Stock into a larger number of shares, (iii) combines (including by way of reverse
stock split) outstanding shares of Common Stock into a smaller number of shares, or (iv) issues by reclassification of shares of the
Common Stock any shares of capital stock of the Company, then in each case the Exercise Price shall be multiplied by a fraction of which
the numerator shall be the number of shares of Common Stock (excluding treasury shares, if any) outstanding immediately before such event
and of which the denominator shall be the number of shares of Common Stock outstanding immediately after such event, and the number of
shares issuable upon exercise of this Warrant shall be proportionately adjusted such that the aggregate Exercise Price of this Warrant
shall remain unchanged. Any adjustment made pursuant to this Section 3(a) shall become effective immediately after the record date for
the determination of stockholders entitled to receive such dividend or distribution and shall become effective immediately after the
effective date in the case of a subdivision, combination or re-classification.

 

b) Subsequent
Rights Offerings. In addition to any adjustments pursuant to Section 3(a) above, if at any time the Company grants, issues or
sells any Common Stock Equivalents or rights to purchase stock, warrants, securities or other property pro rata to all (or
substantially all) of the record holders of any class of shares of Common Stock (the “Purchase Rights”), then the
Holder will be entitled to acquire, upon the terms applicable to such Purchase Rights, the aggregate Purchase Rights which the
Holder could have acquired if the Holder had held the number of shares of Common Stock acquirable upon complete exercise of this
Warrant (without regard to any limitations on exercise hereof, including without limitation, the Beneficial Ownership Limitation)
immediately before the date on which a record is taken for the grant, issuance or sale of such Purchase Rights, or, if no such
record is taken, the date as of which the record holders of shares of Common Stock are to be determined for the grant, issue or sale
of such Purchase Rights (provided, however, that to the extent that the Holder’s right to participate in any
such Purchase Right would result in the Holder exceeding the Beneficial Ownership Limitation, then the Holder shall not be entitled
to participate in such Purchase Right to such extent (or beneficial ownership of such shares of Common Stock as a result of such
Purchase Right to such extent) and such Purchase Right to such extent shall be held in abeyance for the Holder until such time, if
ever, as its right thereto would not result in the Holder exceeding the Beneficial Ownership Limitation).

 

    	8

    	 

    

 

c) Pro
Rata Distributions. During such time as this Warrant is outstanding, if the Company shall declare or make any dividend or other distribution
of its assets (or rights to acquire its assets) to all (or substantially all) holders of shares of Common Stock, by way of return of
capital or otherwise (including, without limitation, any distribution of cash, stock or other securities, property or options by way
of a dividend, spin off, reclassification, corporate rearrangement, scheme of arrangement or other similar transaction) (a “Distribution”),
at any time after the issuance of this Warrant, then, in each such case, the Holder shall be entitled to participate in such Distribution
to the same extent that the Holder would have participated therein if the Holder had held the number of shares of Common Stock acquirable
upon complete exercise of this Warrant (without regard to any limitations on exercise hereof, including without limitation, the Beneficial
Ownership Limitation) immediately before the date of which a record is taken for such Distribution, or, if no such record is taken, the
date as of which the record holders of shares of Common Stock are to be determined for the participation in such Distribution (provided, however,
that to the extent that the Holder’s right to participate in any such Distribution would result in the Holder exceeding the Beneficial
Ownership Limitation, then the Holder shall not be entitled to participate in such Distribution to such extent (or in the beneficial
ownership of any shares of Common Stock as a result of such Distribution to such extent) and the portion of such Distribution shall be
held in abeyance for the benefit of the Holder until such time, if ever, as its right thereto would not result in the Holder exceeding
the Beneficial Ownership Limitation). 

 

d) Fundamental
Transaction. If, at any time while the Warrants are outstanding,

 

	 	(i)	the
    Company, directly or indirectly, in one or more related transactions effects any merger or consolidation of the Company with or into
    another person;
	 	 	 
	 	(ii)	the
    Company (and all of the Subsidiaries, taken as a whole), directly or indirectly, effects any sale, lease, license, assignment, transfer,
    conveyance or other disposition of all or substantially all of its assets in one or a series of related transactions;
	 	 	 
	 	(iii)	any
    direct or indirect purchase offer, tender offer or exchange offer (whether by the Company or another person) is completed pursuant
    to which holders of shares of Common Stock are permitted to sell, tender or exchange their shares for other securities, cash or property
    and has been accepted by the holders of 50% or more of the Company’s shares of Common Stock or 50% or more of the total voting
    power of the Company’s shares of Common Stock; 
	 	 	 
	 	(iv)	the
    Company, directly or indirectly, in one or more related transactions effects any reclassification, reorganization or recapitalization
    of shares of Common Stock or any compulsory share exchange pursuant to which the shares of Common Stock are effectively converted
    into or exchanged for other securities, cash or property, or 

 

    	9

    	 

    

 

	 	(v)	the
    Company, directly or indirectly, in one or more related transactions consummates a stock or share purchase agreement or other business
    combination (including, without limitation, a reorganization, recapitalization, spin-off or scheme of arrangement) with another person
    or group of persons whereby such other person or group acquires 50% or more of the Company’s shares of Common Stock or 50%
    or more of the total voting power of the Company’s shares of Common Stock (each a “Fundamental Transaction”),

 

then,
upon any subsequent exercise of a Warrant, the Holder shall have the right to receive, for each Warrant Share that would have been issuable
upon such exercise immediately prior to the occurrence of such Fundamental Transaction, at the option of the Holder (without regard to
any limitation in Section 2(e) on the exercise of this Warrant), the number of shares of capital stock of the successor or acquiring
corporation or of the Company, if it is the surviving corporation, or depositary shares representing those shares, and any additional
consideration (the “Alternate Consideration”) receivable as a result of such Fundamental Transaction by a holder of
the number of shares of Common Stock for which this Warrant is exercisable immediately prior to such Fundamental Transaction (without
regard to any Beneficial Ownership Limitation in Section 2(e)). For purposes of any such exercise, the determination of the Exercise
Price shall be appropriately adjusted to apply to such Alternate Consideration based on the amount of Alternate Consideration issuable
in respect of one share of Common Stock in such Fundamental Transaction and the Company shall apportion the Exercise Price among the
Alternate Consideration in a reasonable manner reflecting the relative value of any different components of the Alternate Consideration.
If holders of Common Stock are given any choice as to the securities, cash or property to be received in a Fundamental Transaction, then
the Holder shall be given the same choice as to the Alternate Consideration it receives upon any exercise of this Warrant following such
Fundamental Transaction.

 

Notwithstanding
anything to the contrary, in the event of a Fundamental Transaction, the Company or any Successor Entity (as defined below) shall, at
the Holder’s option, exercisable at any time concurrently with, or within 30 days after, the consummation of the Fundamental Transaction
(or, if later, the date of the public announcement of the applicable Fundamental Transaction), purchase this Warrant from the Holder
by paying to the Holder an amount of cash equal to the Black Scholes Value (as defined below) of the remaining unexercised portion of
this Warrant on the date of the consummation of such Fundamental Transaction; provided, however, that, if the Fundamental Transaction
is not within the Company’s control, including not approved by the Company’s Board of Directors, Holder shall only be entitled
to receive from the Company or any Successor Entity the same type or form of consideration (and in the same proportion), at the Black
Scholes Value of the unexercised portion of this Warrant, that is being offered and paid to the holders of shares of Common Stock of
the Company in connection with the Fundamental Transaction, whether that consideration be in the form of cash, stock or any combination
thereof, or whether the holders of shares of Common Stock are given the choice to receive from among alternative forms of consideration
in connection with the Fundamental Transaction; provided, further, that if holders of shares of Common Stock of the Company are not offered
or paid any consideration in such Fundamental Transaction, such holders of Common Stock will be deemed to have received common stock
of the Successor Entity (which Entity may be the Company following such Fundamental Transaction) in such Fundamental Transaction. 

 

    	10

    	 

    

 

“Black
Scholes Value” means the value of this Warrant based on the Black-Scholes Option Pricing Model obtained from the “OV”
function on Bloomberg determined as of the day of consummation of the applicable Fundamental Transaction for pricing purposes and reflecting
(A) a risk-free interest rate corresponding to the U.S. Treasury rate for a period equal to the time between the date of the public announcement
of the applicable contemplated Fundamental Transaction and the Termination Date, (B) an expected volatility equal to the greater of 100%
and the 100 day volatility obtained from the HVT function on Bloomberg (determined utilizing a 365 day annualization factor) as of the
Trading Day immediately following the public announcement of the applicable contemplated Fundamental Transaction, (C) the underlying
price per share used in such calculation shall be the greater of (i) the sum of the price per share being offered in cash, if any, plus
the value of any non-cash consideration, if any, being offered in such Fundamental Transaction and (ii) the highest VWAP during the period
beginning on the Trading Day immediately preceding the public announcement of the applicable contemplated Fundamental Transaction (or
the consummation of the applicable Fundamental Transaction, if earlier) and ending on the Trading Day of the Holder’s request pursuant
to this Section 3(d) and (D) a remaining option time equal to the time between the date of the public announcement of the applicable
contemplated Fundamental Transaction and the Termination Date and (E) a zero cost of borrow. The payment of the Black Scholes Value will
be made by wire transfer of immediately available funds (or such other consideration) within the later of (i) five (5) Business Days
of the Holder’s election and (ii) the date of consummation of the Fundamental Transaction.

 

The
Company shall cause any successor entity in a Fundamental Transaction in which the Company is not the survivor (the “Successor
Entity”), to assume in writing all of the obligations of the Company under this Warrant and the other Transaction Documents
in accordance with the provisions of this Section 3(d) pursuant to written agreements in form and substance reasonably satisfactory to
the Holder and approved by the Holder (without unreasonable delay) prior to such Fundamental Transaction and shall, at the option of
the Holder, deliver to the Holder in exchange for this Warrant a security of the Successor Entity evidenced by a written instrument substantially
similar in form and substance to this Warrant that is exercisable for a corresponding number of shares of capital stock of such Successor
Entity (or its parent entity) equivalent to the shares of Common Stock acquirable and receivable upon exercise of this Warrant (without
regard to any limitations on the exercise of this Warrant) prior to such Fundamental Transaction and with an exercise price which applies
the exercise price hereunder to such shares of capital stock (but taking into account the relative value of the shares of Common Stock
pursuant to such Fundamental Transaction and the value of such shares of capital stock, such number of shares of capital stock and such
exercise price being for the purpose of protecting the economic value of this Warrant immediately prior to the consummation of such Fundamental
Transaction), and which is reasonably satisfactory in form and substance to the Holder. Upon the occurrence of any such Fundamental Transaction,
the Successor Entity shall be added to the term “Company” under this Warrant (so that from and after the occurrence or consummation
of such Fundamental Transaction, each and every provision of this Warrant and the other Transaction Documents referring to the “Company”
shall refer instead to each of the Company and the Successor Entity or Successor Entities, jointly and severally), and the Successor
Entity or Successor Entities, jointly and severally with the Company, may exercise every right and power of the Company prior thereto
and the Successor Entity or Successor Entities shall assume all of the obligations of the Company prior thereto under this Warrant and
the other Transaction Documents with the same effect as if the Company and such Successor Entity or Successor Entities, jointly and severally,
had been named as the Company herein. For the avoidance of doubt, the Holder shall be entitled to the benefits of the provisions of this
Section 3(d) regardless of whether the Company has sufficient authorized shares of Common Stock for the issuance of Warrant Shares.

 

    	11

    	 

    

 

e) Reserved.

 

f) Calculations. All
calculations under this Section 3 shall be made to the nearest cent or the nearest 1/100th of a share, as the case may be. For purposes
of this Section 3, the number of shares of Common Stock deemed to be issued and outstanding as of a given date shall be the sum of the
number of shares of Common Stock (excluding treasury shares, if any) issued and outstanding.

 

g) Notice
to Holder.

 

i. Adjustment
to Exercise Price. Whenever the Exercise Price is adjusted pursuant to any provision of this Section 3, the Company shall promptly
deliver to the Holder by email a notice setting forth the Exercise Price after such adjustment and any resulting adjustment to the number
of Warrant Shares and setting forth a brief statement of the facts requiring such adjustment. 

 

ii. Notice
to Allow Exercise by Holder. If (A) the Company shall declare a dividend (or any other distribution in whatever form) on the Common
Stock, (B) the Company shall declare a special nonrecurring cash dividend on or a redemption of the Common Stock, (C) the Company shall
authorize the granting to all holders of the Common Stock rights or warrants to subscribe for or purchase any shares of capital stock
of any class or of any rights, (D) the approval of any stockholders of the Company shall be required in connection with any reclassification
of the Common Stock, any consolidation or merger to which the Company is a party, any sale or transfer of all or substantially all of
the assets of the Company, or any compulsory share exchange whereby the Common Stock is converted into other securities, cash or property,
or (E) the Company shall authorize the voluntary or involuntary dissolution, liquidation or winding up of the affairs of the Company,
then, in each case, the Company shall cause to be delivered by email to the Holder at its last email address as it shall appear upon
the Warrant Register of the Company, at least 20 calendar days prior to the applicable record or effective date hereinafter specified,
a notice stating (x) the date on which a record is to be taken for the purpose of such dividend, distribution, redemption, rights or
warrants, or if a record is not to be taken, the date as of which the holders of the Common Stock of record to be entitled to such dividend,
distributions, redemption, rights or warrants are to be determined or (y) the date on which such reclassification, consolidation, merger,
sale, transfer or share exchange is expected to become effective or close, and the date as of which it is expected that holders of the
Common Stock of record shall be entitled to exchange their shares of the Common Stock for securities, cash or other property deliverable
upon such reclassification, consolidation, merger, sale, transfer or share exchange; provided that the failure to deliver such notice
or any defect therein or in the delivery thereof shall not affect the validity of the corporate action required to be specified in such
notice. To the extent that any notice provided in this Warrant constitutes, or contains, material, non-public information regarding the
Company, the Company shall simultaneously file such notice with the Commission pursuant to a Report of Foreign Private Issuer on Form
6-K. The Holder shall remain entitled to exercise this Warrant during the period commencing on the date of such notice to the effective
date of the event triggering such notice except as may otherwise be expressly set forth herein.

 

    	12

    	 

    

 

Section
4. Transfer of Warrant.

 

a) Transferability.
Subject to compliance with any applicable securities laws and the conditions set forth in Section 4(d) hereof and to the provisions of
Section 4.1 of the Purchase Agreement, this Warrant and all rights hereunder (including, without limitation, any registration rights)
are transferable, in whole or in part, upon surrender of this Warrant at the principal office of the Company or its designated agent,
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,
such payment, the Company shall execute and deliver a new Warrant or Warrants in the name of the assignee or assignees, as applicable,
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. Notwithstanding anything herein to the contrary,
the Holder shall not be required to physically surrender this Warrant to the Company unless the Holder has assigned this Warrant in full,
in which case, the Holder shall surrender this Warrant to the Company within three (3) Trading Days of the date on which the Holder delivers
an assignment form to the Company assigning this Warrant in full. The Warrant, if properly assigned in accordance herewith, may be exercised
by a new holder for the purchase of Warrant Shares without having a new Warrant issued. 

 

b) New
Warrants. 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 4(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. All Warrants issued on transfers or exchanges shall be dated the initial issuance date of this Warrant and
shall be identical with this Warrant except as to the number of Warrant Shares issuable pursuant thereto.

 

c) Warrant
Register. The Company shall register this Warrant, upon records to be maintained by the Company for that purpose (the “Warrant
Register”), in the name of the record Holder hereof from time to time. The Company may deem and treat the registered Holder
of this Warrant as the absolute owner hereof for the purpose of any exercise hereof or any distribution to the Holder, and for all other
purposes, absent actual notice to the contrary.

 

d) Transfer
Restrictions. If, at the time of the surrender of this Warrant in connection with any transfer of this Warrant, the transfer of this
Warrant shall not be either (i) registered pursuant to an effective registration statement under the Securities Act and under applicable
state securities or blue sky laws or (ii) eligible for resale without volume or manner-of-sale restrictions or current public information
requirements pursuant to Rule 144, the Company may require, as a condition of allowing such transfer, that the Holder or transferee of
this Warrant, as the case may be, comply with the provisions of Section 5.7 of the Purchase Agreement.

 

e) Representation
by the Holder. The Holder, by the acceptance hereof, represents and warrants that it is acquiring this Warrant and, upon any exercise
hereof, will acquire the Warrant Shares issuable upon such exercise, for its own account and not with a view to or for distributing or
reselling such Warrant Shares or any part thereof in violation of the Securities Act or any applicable state securities law, except pursuant
to sales registered or exempted under the Securities Act.

 

Section
5. Miscellaneous.

 

a) No
Rights as Stockholder until Exercise; No Settlement in Cash. This Warrant does not entitle the Holder to any voting rights, dividends
or other rights as a stockholder of the Company prior to the exercise hereof as set forth in Section 2(d)(i), except as expressly set
forth in Section 3. Without limiting the rights of a Holder to receive Warrant Shares on a “cashless exercise” pursuant to
Section 2(c) or to receive cash payments contemplated pursuant to Sections 2(d)(i) and 2(d)(iv), in no event, including if the Company
is for any reason unable to issue and deliver Warrant Shares upon exercise of this Warrant as required pursuant to the terms hereof,
shall the Company be required to net cash settle an exercise of this Warrant or cash settle in any other form.

 

    	13

    	 

    

 

b) 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.

 

c) 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 not be a Trading Day, then, such action may be taken or such right may be exercised on the next succeeding Trading Day.

 

d) 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 issuing the necessary 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 Trading Market upon which the Common Stock may be listed.
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 and payment for such Warrant Shares in accordance herewith, be
duly authorized, validly issued, fully paid and nonassessable (which means that no further sums are required to be paid by the holders
thereof in connection with the issue thereof) and free from all taxes, liens and charges created by the Company in respect of the issue
thereof (other than taxes in respect of any transfer occurring contemporaneously with such issue).

 

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 certificate of incorporation 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 (i) 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, (ii) 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 (iii) 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.

 

    	14

    	 

    

 

Before
taking any action that 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.

 

e) Governing
Law. All questions concerning the construction, validity, enforcement and interpretation of this Warrant shall be governed by and
construed and enforced in accordance with the law of the State of New York. Each party agrees that all legal proceedings concerning the
interpretations, enforcement and defense of the transactions contemplated by this Warrant (whether brought against a party hereto or
their respective affiliates, directors, officers, shareholders, partners, members, employees or agents) shall be commenced exclusively
in the state and federal courts sitting in the City of New York. Each party hereby irrevocably submits to the exclusive jurisdiction
of the state and federal courts sitting in the City and County of New York, 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 improper or is an inconvenient venue for such proceeding. 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 via registered or certified mail
or overnight delivery (with evidence of delivery) to such party at the address in effect for notices to it under this Warrant and agrees
that such service shall constitute good and sufficient service of process and notice thereof. Nothing contained herein shall be deemed
to limit in any way any right to serve process in any other manner permitted by law. If either party shall commence an action, suit or
proceeding to enforce any provisions of this Warrant, the prevailing party in such action, suit or proceeding shall be reimbursed by
the other party for their reasonable attorneys’ fees and other costs and expenses incurred with the investigation, preparation
and prosecution of such action or proceeding. Notwithstanding the foregoing, nothing in this paragraph shall limit or restrict the federal
district court in which a Holder may bring a claim under the federal securities laws.

 

f) Restrictions.
The Holder acknowledges that the Warrant Shares acquired upon the exercise of this Warrant, if not registered, and the Holder does not
utilize cashless exercise, will have restrictions upon resale imposed by state and federal securities laws.

 

g) Non-waiver
and Expenses. 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 the Holder’s rights, powers or remedies. No provision of this Warrant shall be construed
as a waiver by the Holder of any rights which the Holder may have under the federal securities laws and the rules and regulations of
the Commission thereunder. Without limiting any other provision of this Warrant or the Purchase Agreement, if the Company willfully and
knowingly fails to comply with any provision of this Warrant, which results in any material damages to the Holder, the Company shall
pay to the Holder such amounts as shall be sufficient to cover any costs and expenses including, but not limited to, reasonable attorneys’
fees, including those of appellate proceedings, incurred by the Holder in collecting any amounts due pursuant hereto or in otherwise
enforcing any of its rights, powers or remedies hereunder. 

 

    	15

    	 

    

 

h) Notices.
Any and all notices or other communications or deliveries to be provided by the Holders hereunder including, without limitation, any
Notice of Exercise, shall be in writing and delivered personally, by e-mail, or sent by a nationally recognized overnight courier service,
addressed to the Company, at Bruush Oral Care Inc., 128 West Hastings Street, Unit 210, Vancouver, British Columbia V6B 1G8, Canada,
Attention: Aneil Singh Manhas, Chief Executive Officer, E-mail: aneil@bruush.com, or such other email address or address as the Company
may specify for such purposes by notice to the Holders. Any and all notices or other communications or deliveries to be provided by the
Company hereunder shall be in writing and delivered personally, by e-mail, or sent by a nationally recognized overnight courier service
addressed to each Holder at the e-mail address or address of such Holder appearing on the books of the Company. Any notice or other communication
or deliveries hereunder shall be deemed given and effective on the earliest of (i) the time of transmission, if such notice or communication
is delivered via e-mail at the e-mail address set forth in this Section prior to 5:30 p.m. (New York City time) on any date, (ii) the
next Trading Day after the time of transmission, if such notice or communication is delivered via e-mail at the e-mail address set forth
in this Section on a day that is not a Trading Day or later than 5:30 p.m. (New York City time) on any Trading Day, (iii) the second
Trading Day following the date of mailing, if sent by U.S. nationally recognized overnight courier service, or (iv) upon actual receipt
by the party to whom such notice is required to be given. To the extent that any notice provided hereunder constitutes, or contains,
material, non-public information regarding the Company, the Company shall simultaneously file such notice with the Commission pursuant
to a Report of Foreign Private Issuer on Form 6-K.

 

i) Limitation
of Liability. No provision hereof, in the absence of any affirmative action by the Holder to exercise this Warrant to purchase Warrant
Shares, and no enumeration herein of the rights or privileges of the Holder, shall give rise to any liability of the 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.

 

j) Remedies.
The 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 and not to assert the defense in any
action for specific performance that a remedy at law would be adequate.

 

k) 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 and permitted assigns of the Company and the successors and permitted assigns of Holder.
The provisions of this Warrant are intended to be for the benefit of any Holder from time to time of this Warrant and shall be enforceable
by the Holder or holder of Warrant Shares.

 

l) Amendment.
This Warrant may be modified or amended or the provisions hereof waived with the written consent of the Company, on the one hand, and
the Holder of this Warrant, on the other hand.

 

m) 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.

 

n) 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.

 

(Signature
Page Follows)

 

    	16

    	 

    

 

IN
WITNESS WHEREOF, the Company has caused this Warrant to be executed by its officer thereunto duly authorized as of the date first above
indicated.

 

	 	BRUUSH
    ORAL CARE INC.
	 	 	 
	 	By:	 
	 	Name:	Aneil
    Manhas
	 	Title:	Chief
    Executive Officer

 

    	17

    	 

    

 

EXHIBIT
A

NOTICE
OF EXERCISE

 

TO: BRUUSH
ORAL CARE INC.

 

(1)
The undersigned hereby elects to purchase ________ Warrant Shares of the Company pursuant to the terms of the attached Warrant dated
December __, 2022 (only if exercised in full), and tenders herewith payment of the exercise price in full, together with all applicable
transfer taxes, if any.

 

(2)
Payment shall take the form of (check applicable box):

 

☐
in lawful money of the United States; or

☐
if permitted the cancellation of such number of Warrant Shares as is necessary, in accordance with the formula set forth in subsection
2(c), to exercise this Warrant with respect to the maximum number of Warrant Shares purchasable pursuant to the cashless exercise procedure
set forth in subsection 2(c).

 

(3)
Please issue 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 DWAC Account Number:

	 	 	 
	 	 	 
	 	 	 

 

(4) Accredited
Investor. The undersigned is an “accredited investor” as defined in Regulation D promulgated under the Securities Act
of 1933, as amended.

 

[SIGNATURE
OF HOLDER]

 

	Name
    of Investing Entity: 	 
	 	 
	Signature
    of Authorized Signatory of Investing Entity:	 
	 	 
	Name
    of Authorized Signatory: 	 
	 	 
	Title
    of Authorized Signatory: 	 
	 	 
	Date:
    	 

 

    	18

    	 

    

 

EXHIBIT
B

ASSIGNMENT
FORM

 

(To
assign the foregoing Warrant, execute this form and supply required information. Do not use this form to exercise this Warrant to purchase
shares.)

 

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

 

	Name:	 
	 	(Please
    Print)
	 	 
	Address:	 
	 	(Please
    Print)
	Phone
    Number:	 
	 	 
	Email
    Address:	 

 

	Dated:
    _______________ __, ______	 

 

	Holder’s
    Signature:	 	 

 

	Holder’s
    Address:	 	 

 

    	19

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