Document:

Exhibit 4.3

BALLISTIC RECOVERY SYSTEMS, INC

SUBSCRIPTION
AGREEMENT

Units
including Common Stock and Warrants to Purchase Common Stock

 

SUBSCRIPTION AGREEMENT

AND

LETTER OF
INVESTMENT INTENT

 

INSTRUCTIONS

To purchase Units
of common stock and warrants to purchase common stock pursuant to Ballistic
Recovery Systems, Inc.’s Confidential Offering Memorandum dated September 15,
2006 please:  (i) review the Subscription
Agreement and Letter of Investment Intent (the “Subscription Agreement”); (ii)
complete Section 4 of the Subscription Agreement regarding accredited investor
status; (iii) complete Section 12 of the Subscription Agreement regarding
relationships to brokerage firms; (iv) complete, sign and date the appropriate
signature pages (individual subscribers should sign and date in Section
VI (A); entity subscribers should sign and date in Section VI (B) and
individual subscribers who wish to hold Units in an IRA account should sign and
date in Section VI (A) and VI (C); and (v) send the Investor check payable to “Ballistic
Recovery Systems, Inc. Escrow Account,” together with the completed
Subscription Agreement to                         .

____________________________________________________________________________________

THE COMPANY WILL NOT ACCEPT ANY
SUBSCRIPTION AGREEMENT THAT IS NOT FULLY AND ACCURATELY COMPLETED, DATED AND
SIGNED.

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Investor Full Name:
_______________________________

Number of Units
Subscribed For: ___________________

BALLISTIC
RECOVERY SYSTEMS, INC.

SUBSCRIPTION
AGREEMENT AND LETTER OF INVESTMENT INTENT

THIS IS AN IMPORTANT LEGAL
DOCUMENT.  READ EACH PART OF IT
CAREFULLY.

This subscription,
submitted as of the date set forth on the Signature Page, is between Ballistic
Recovery Systems, Inc., a Minnesota corporation (the “Company”), and the
undersigned subscriber (the “Subscriber”).

1.                                       Offer
to Purchase.  The Subscriber hereby
offers to purchase that number of Units set forth on the Signature Page (the “Units”)
and hereby tenders the Subscriber’s check payable to “Ballistic Recovery Systems,
Inc. Escrow Account” in the aggregate dollar amount set forth on the Signature
Page at a per Unit purchase price of $5.44. 
There is a minimum purchase of 4,000 Units ($21,760).  By execution hereof, the Subscriber
acknowledges that the Company is relying upon the accuracy and completeness of
the representations contained herein in complying with its obligations under
applicable securities laws.

2.                                       Representations
and Warranties of the Company.  In
consideration of the Subscriber’s purchase of the Units, the Company represents
and warrants to the Subscriber as follows:

a.                                       Organization.  The Company is a validly existing corporation
under the laws of the State of Minnesota.

b.                                      Good
Standing.  The Company is in good
standing under the laws of the State of Minnesota, and there are no proceedings
or actions pending to limit or impair any of its powers, rights and privileges,
or to dissolve it.

c.                                       Corporate
Authorization.  The execution and
delivery of this Agreement and the consummation of the transaction contemplated
hereby have been duly authorized by proper corporate action of the Company.

3.                                       Representations
and Warranties of Subscriber.  The
Subscriber hereby represents and warrants to the Company and its officers,
directors, shareholders, employees and agents as follows:

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a.                                       Information
About the Company.  The Subscriber
has received and reviewed the Company’s Confidential Offering Memorandum dated
September 15, 2006, and all attachments and exhibits thereto, including the
Company’s (i) Form 10-KSB for the year ended September 30, 2005, (ii) Form
10-QSB for the quarter ended March 31, 2006, (iii) Form 10-QSB for the quarter
ended June 30, 2006 and (iv) proxy statement relating to the 2006 Annual
Meeting of Shareholders, and has obtained all information about the Company as
the Subscriber believes relevant to the decision to purchase the Units. The
Subscriber has also had the opportunity to ask questions of, and to receive
answers from, the Company or an agent or a representative of the Company
concerning the terms and conditions of the investment and the business and
affairs of the Company and to obtain any additional information necessary to
verify such information, and the Subscriber has received such information
concerning the Company as the Subscriber considers necessary or advisable in
order to form a decision concerning an investment in the Company.

The Subscriber understands that any business plan, marketing plan,
financial modeling or similar document concerning the Company is inherently
forward-looking.  The Subscriber
represents that the Subscriber has viewed the information set forth therein
with a critical frame of mind and, to the extent that information contained in
any such document was deemed by the Subscriber to be important information in
making an investment decision, the Subscriber has discussed such information
with the officers and other personnel of the Company in order to form a better
judgment regarding the usefulness of such information.  The Subscriber agrees that no statement in
any such document, even if framed as a factual statement, will, of itself,
constitute a factual representation by the Company in light of the various
purposes for which any such document may have been created.

b.                                      Forward-Looking
Information.  The Subscriber acknowledges
and understands that any information provided about the Company’s future plans
and prospects is uncertain and subject to all of the uncertainties inherent in
future predictions.

c.                                       No
Review by Federal or State Regulators. 
The Subscriber understands that this transaction has not been
scrutinized by the United States Securities and Exchange Commission (the “Commission”)
or by any state securities or other authority and, because of the small number
of persons solicited to invest in the Units and the private nature of the
Offering, that all documents, records, and books pertaining to this investment
have been made available to the Subscriber and the Subscriber’s
representatives, such as attorneys, accountants and/or purchaser
representatives.

d.                                      High
Degree of Risk.  The Subscriber
realizes that this investment involves a high degree of risk, including the
risk of loss of all investment in the Company.

e.                                       Ability
to Bear the Risk.  The Subscriber is
able to bear the economic risk of the investment, including the total loss of
such investment.

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f.                                         Appropriate
Investment.  The Subscriber believes,
in light of the information provided pursuant to paragraph 3(a) above,
that investing funds pursuant to the terms of this Agreement is an appropriate
and suitable investment for the Subscriber.

g.                                      Financial
Condition.  The Subscriber’s current
financial condition is such that (and the Subscriber expects the Subscriber’s
financial condition to be such that in the near future) the Subscriber does not
have any present or contemplated need to dispose of any portion of the Units to
satisfy any existing or contemplated undertaking, need or indebtedness.

h.                                      Business
Sophistication.  The Subscriber
(i) is experienced and knowledgeable in financial and business matters to
the extent that the Subscriber is capable of evaluating the merits and risks of
the prospective investment in the Units or (ii) if the Subscriber does not
so believe, or if the Subscriber has been instructed by the Company to
designate a purchaser representative to supplement the Subscriber’s knowledge
and experience for the purpose of evaluating the merits and risks of the
prospective investment in the Units, the Subscriber has provided the Company
with the identity of such purchaser representative and such information
concerning the knowledge and experience in financial and business matters of
such a purchaser representative, either directly or by making such purchaser
representative available for interview, necessary to enable a determination
that such purchaser representative, together with the undersigned, have such
knowledge and experience in financial and business matters that they are
capable of evaluating the merits and risks of the prospective investment in the
Units.  In addition to designating a purchaser
representative, if necessary, the Subscriber has obtained, to the extent the
Subscriber deems necessary, personal and professional advice with respect to
the risks inherent in the investment in the Units in light of the Subscriber’s
financial condition and investment needs. 
The Subscriber and the Subscriber’s purchaser representative, if any,
have been given access to full and complete information regarding the Company
and have utilized such access to their satisfaction for the purpose of obtaining
information and, particularly, the Subscriber or the Subscriber’s purchaser
representative, if any, have obtained, and have had the opportunity to obtain,
information from the Company as set forth in paragraph 3(a) above.

i.                                          Residency.  The Subscriber is a resident of the state and
country set forth on the Signature Page. 
The Units are being purchased by the undersigned in the undersigned’s
name solely for the undersigned’s own beneficial interest and not as nominee
for, on behalf of, for the beneficial interest of, or with the intention to
transfer to, any other person, trust, or organization.

j.                                          Subscription.  The Subscriber understands that the payment
made to the Company may immediately become funds of and may be used by the
Company once accepted on the conditions described in the Memorandum.  The Company is free to reject any
subscription in whole or in part.  The
Subscriber understands that if 

 4
 

 

the Company determines to reject this subscription, any funds returned
to the Subscriber will be without deduction therefrom or interest thereon.

k.                                       No
General Solicitation.  The Subscriber’s
purchase of the Units is not the result of any general solicitation or general
advertising, including, but not limited to (i) any advertisement, article,
notice or other communication published in any newspaper, magazine or similar
media or broadcast over television or radio; and (ii) any seminar or
meeting whose attendees have been invited by any general solicitation or
general advertising.

l.                                          Legal
Age.  The Subscriber is of legal age
(as established in the Subscriber’s state of residence) and is under no
disability with respect to entering into a contractual relationship.

m.                                    Not
Subject to Backup Withholding.  The
Subscriber certifies, under penalty of perjury, that the Subscriber is not
subject to the backup withholding provisions of the Internal Revenue Code of
1986, as amended.  (Note:  The Subscriber is subject to backup
withholding if:  (i) the Subscriber
fails to furnish its Social Security Number or Taxpayer Identification Number
herein; (ii) the Internal Revenue Service notifies the Company that the
Subscriber furnished an incorrect Social Security Number or Taxpayer
Identification Number; (iii) the Subscriber is notified that it is subject
to backup withholding; or (iv) the Subscriber fails to certify that it is
not subject to backup withholding or the Subscriber fails to certify the
Subscriber’s Social Security Number or Taxpayer Identification Number.)

n.                                      Legal
Representation.  The Subscriber
understands that: (i) the Company has engaged legal counsel to provide
assistance to the Company in connection with the offer and sale of securities
contemplated herein; (ii) legal counsel engaged by the Company does not
represent the Subscriber or the Subscriber’s interests; (iii) such legal
counsel did not prepare the Company’s disclosure documents and has conducted
only nominal due diligence in connection with the Offering and the Company; and
(iv) the Subscriber is not relying on legal counsel engaged by the
Company.  The Subscriber has had the
opportunity to engage, and obtain advice from, the Subscriber’s own legal
counsel with respect to the investment contemplated herein.

4.                                       Accredited
Status.  The Subscriber represents
and warrants as follows (please INITIAL all applicable items):

INDIVIDUALS:

___                           (i)            The Subscriber is an individual with
a net worth, or a joint net worth together with his or her spouse, in excess of
$1,000,000.  (In calculating net worth,
the Investor may include equity in personal property and real estate, including
the Investor principal residence, cash, short-term investments, stock and
securities.  Equity in personal property
and real 

 5
 

 

estate should be based on the fair market value of
such property less any debt secured by such property.)

___                           (ii)           The Subscriber is an individual that
had an individual income in excess of $200,000 in each of the prior two years
and reasonably expects an income in excess of $200,000 in the current year.

___                           (iii)          The Subscriber is an individual that
had with his or her spouse joint income in excess of $300,000 in each of the
prior two years and reasonably expects joint income in excess of $300,000 in
the current year.

___                           (iv)          The Subscriber is a director or
executive officer of the Company.

ENTITIES (Please provide a copy of the entity’s
charter documents):

___                           (i)            The Subscriber is a (initial one):

___         (A)          General
Partnership

___         (B)           Limited
Liability Partnership

___         (C)           Limited
Partnership

___         (D)          Limited
Liability Company

___         (E)           Corporation

___         (F)           Business
Trust

___         (G)           Other Entity (please specify):  _________________

___                           (ii)           The Subscriber is an entity, and is
an “Accredited Investor” as defined in Rule 501(a) of Regulation D
under the Securities Act of 1933, as amended (the “Act”).  This representation is based on the following
(initial one or more, as applicable):

___                           (A)          The Subscriber (or, in the case of a
trust, the undersigned trustee) is a bank or savings and loan association as
defined in Sections 3(a)(2) and 3(a)(5)(A), respectively, of the Act
acting either in its individual or fiduciary capacity.

___                           (B)           The Subscriber is a broker/dealer
registered pursuant to the Securities Exchange Act of 1934.

___                           (C)           The Subscriber is an insurance
company as defined in Section 2(13) of the Act.

___                           (D)          The Subscriber is an investment
company registered under the Investment Company Act of 1940 or a business
development company as defined in Section 2(a)(48) of that Act.

 6
 

 

___                           (E)           The Subscriber is a Small Business
Investment Company licensed by the U.S. Small Business Administration under
Section 301(c) or (d) of the Small Business Investment Act of 1958.

___                           (F)           The Subscriber is an employee benefit
plan within the meaning of Title I of the Employee Retirement Income
Security Act of 1974 and either (initial one or more, as applicable):

___                           (1)           The investment decision is made by a
plan fiduciary, as defined in Section 3(21) of such Act, which is either a
bank, savings and loan association, insurance company, or registered investment
adviser.

___                           (2)           The employee benefit plan has total
assets in excess of $5,000,000.

___                           (3)           The plan is a self-directed plan with
investment decisions made solely by persons who are “Accredited Investors” as
defined under the Act.

___                           (G)           The Subscriber is a private business
development company as defined in Section 202(a)(22) of the Investment
Advisers Act of 1940.

___                           (H)          The Subscriber has total assets in
excess of $5,000,000, was not formed for the specific purpose of acquiring
Units of the Company and is one or more of the following (initial one or
more, as appropriate):

___                           (1)           An organization described in
Section 501(c)(3) of the Internal Revenue Code.

___                           (2)           A corporation.

___                           (3)           A Massachusetts or similar business
trust.

___                           (4)           A partnership.

___                           (5)           A limited liability company.

___                           (I)            The Subscriber is a trust with total
assets exceeding $5,000,000, which was not formed for the specific purpose of
investing in the Company and whose purchase is directed by a person described
in Rule 506(b)(2)(ii) under the Act.

___                           (J)            The Subscriber is an entity, all of
whose equity owners are accredited investors. 
(Please provide written 

 7
 

 

representation of accredited investor status from each
equity owner.)

IF YOU HAVE NOT
INITIALED ANY OF THE FOREGOING TESTS SET FORTH ABOVE, YOU ARE NOT AN ACCREDITED
INVESTOR AND CANNOT PURCHASE ANY UNITS.

___                           (iii)
Entities.  A REPRESENTATIVE OF AN
ENTITY SUBSCRIBER MUST INITIAL HERE . If the Subscriber is an entity, the
individual(s) signing on behalf of the Subscriber and the Subscriber, jointly
and severally, agree and certify that this Agreement has been duly authorized
by all necessary action on the part of the Subscriber, has been duly executed
by an authorized representative of the Subscriber, and is a legal, valid, and
binding obligation of the Subscriber enforceable in accordance with its terms.

5.                                       Investment
Purpose in Acquiring the Units.  The
Subscriber and the Company acknowledge that the Units have not been registered
under the Act or applicable state securities laws and that the Units will be
issued to the Subscriber in reliance on exemptions from the registration
requirements of the Act and applicable state securities laws and in reliance on
the Subscriber’s and the Company’s representations and agreements contained
herein.  The Subscriber is subscribing to
acquire the Units for the account of the Subscriber for investment purposes
only and not with a view to their resale or distribution.  The Subscriber has no present intention to
divide his, her or its participation with others or to resell or otherwise
dispose of all or any part of the Units. 
In making these representations, the Subscriber understands that, in the
view of the Commission, exemption of the Units from the registration
requirements of the Act would not be available if, notwithstanding the
representations of the Subscriber, the Subscriber has in mind merely acquiring
the Units for resale upon the occurrence or non-occurrence of some
predetermined event.

6.                                       Compliance
with Securities Act.  The Subscriber
agrees that if the Units or any part thereof are sold or distributed in the
future, the Subscriber shall sell or distribute them pursuant to the
requirements of the Act and applicable state securities laws.  The Subscriber agrees that the Subscriber
will not transfer any part of the Units without: (i) obtaining a “no
action” letter from the Commission and applicable state securities commissions;
(ii) obtaining an opinion of counsel satisfactory in form and substance to
the Company to the effect that such transfer is exempt from the registration
requirements under the Act and applicable state securities laws; or
(iii) registration.

7.                                       Restrictive
Legend.  The Subscriber agrees that
the Company may place one or more restrictive legends on any certificates
evidencing the Units, containing substantially the following language:

The securities represented by this certificate have
not been registered under the Securities Act of 1933, as amended, have not 

 8
 

 

been registered under any state securities law, and
are subject to a subscription and investment representation agreement.  They may not be sold, offered for sale, or
transferred in the absence of either an effective registration under the
Securities Act of 1933, as amended, and under the applicable state securities
laws, or an opinion of counsel for the Company that such transaction is exempt
from registration under the Securities Act of 1933, as amended, and under the
applicable state securities laws.

9.                                       Stop
Transfer Order.  The Subscriber
agrees that the Company may place a stop transfer order with its registrar and
transfer agent (if any) covering all certificates representing the Units.

10.                                 Relationship
to Brokerage Firms.  (Please answer
the following questions by initialing the appropriate response):

___ YES___ NO: Is the Investor a director, officer, partner, branch
manager, registered representative, employee, shareholder of, or similarly
related to or employed by, a brokerage firm?

___ YES ___ NO: Is the Investor’s spouse, father, mother,
father-in-law, mother-in-law, or any of the Investor’s brothers, sisters,
brothers-in-laws, sisters-in-law or children, or any relative which the
Investor supports, a director, officer, partner, branch manager, registered
representative, employee, shareholder of, or similarly related to or engage by,
a brokerage firm?

___ YES ___ NO: Does the Investor own voting securities of any
brokerage firm?

___ YES ___ NO: If the Subscriber is an entity, is any director,
officer, partner or 5% owner of the Subscriber also a director, officer,
partner, branch manager, registered representative, employee, shareholder of,
or similarly related to or employed by a brokerage firm?

(If the Investor answered YES to any of the foregoing questions, please
contact the Company to provide additional information before the subscription
can be considered.)

11.                                 Binding
Effect.  Neither this Agreement nor
any interest herein shall be assignable by the Subscriber without the prior
written consent of the Company.  The
provisions of this Agreement shall be binding upon and inure to the benefit of
the parties hereto, and their respective heirs, legal representatives,
successors and assigns.

12.                                 Representations
to Survive Delivery.  The
representations, warranties and agreements of the Company and of the Subscriber
contained in this Agreement will remain operative and in full force and effect
and will survive the receipt of funds by the Company, and the issuance to the
Subscriber of the Units.

13.                                 Indemnification.  Subscriber agrees to indemnify the Company,
and each current and future officer, director, employee, agent and shareholder
of the Company, against and to 

 9
 

 

hold them harmless from any damage, loss, liability,
claim or expense including, without limitation, reasonable attorneys’ fees
resulting from or arising out of the inaccuracy or alleged inaccuracy of any of
the representations, warranties or statements of the Subscriber contained in
this Agreement, including without limitation any violation or alleged violation
of the registration requirements of the Act or applicable state law in
connection with any subsequent sale of the Units by Subscriber.

14.                                 Revocation.  Subscriber hereby acknowledges and agrees
that Subscriber is not entitled to cancel, terminate or revoke this Agreement
and that it shall survive the bankruptcy of Subscriber.

15.                                 Arbitration.  The Subscriber further agrees that any
dispute regarding this Agreement or the Subscriber’s investment in the Company
(including without limitation claims pursuant to federal or state securities
laws), including any claim which is made against any Offering agent or broker-dealer
involved in the offer or sale of the Units, shall be resolved by arbitration
which shall be the sole forum for resolution of any such disputes.  Unless otherwise agreed by the parties, any
such proceedings shall be brought in the state of Minnesota, County of
Hennepin, pursuant to the Rules and Code of Arbitration of the America
Arbitration Association, except that if a bona fide claim is made against the
Company, and an Offering agent or broker-dealer is named in connection with
such claim, then such claim shall be brought pursuant to the Rules and Code of
Arbitration of the National Association of Securities Dealers, Inc.

16.                                 Governing
Law; Venue.  This Agreement shall be
governed by, and construed in accordance with, the substantive laws of the
State of Minnesota without reference to Minnesota conflict or choice of law
provisions.  Actions or proceedings
litigated in connection with this Agreement, if any, shall be venued exclusively
in the state and federal courts located in the County of Hennepin, State of
Minnesota.

17.                                 Additional
Information.  Subscriber shall supply
such additional information and documentation relating to Subscriber and any
persons who have any rights or interest in Subscriber as may be requested by
the Company in order to ensure compliance by the Company with applicable
laws.  If at any time prior to the
Company’s acceptance of this Agreement, an adverse change occurs with respect
to the Subscriber such that the information, representations and warranties of
the Subscriber set forth in this Agreement are no longer accurate, the
Subscriber shall immediately notify the Company of the inaccuracy in writing
and shall deliver the updated, accurate information to the Company.

18.                                 Successors
and Assigns.  The representations and
warranties made by the Subscriber in this Agreement are binding on the
Subscriber’s successors and assigns and are made for the benefit of the Company
and any other person who may become liable for violations of applicable securities
laws as a result of the inaccuracy or falsity of any of the Subscriber’s
representations or warranties.

19.                                 Counterparts.  This Agreement may be executed by the Company
and by the Subscriber in separate counterparts, each of which shall be deemed an
original.

 10

20.                                 Acceptance. This
Agreement is not binding on the Company until accepted in writing by an
authorized officer of the Company.

23.                                 THESE
SECURITIES HAVE NOT BEEN REGISTERED UNDER THE FLORIDA SECURITIES ACT IN
RELIANCE UPON AN EXEMPTION THEREFROM. ANY SALE MADE PURSUANT TO SUCH EXEMPTION
IS VOIDABLE BY A FLORIDA PURCHASER WITHIN THREE (3) DAYS AFTER THE FIRST TENDER
OF CONSIDERATION IS MADE BY SUCH PURCHASER TO THE ISSUER, AN AGENT OF THE
ISSUER OR AN ESCROW AGENT IN PAYMENT FOR SUCH SECURITIES. HOWEVER, THIS RIGHT
IS NOT AVAILABLE TO ANY PURCHASER WHO IS A BANK, TRUST COMPANY, SAVINGS
INSTITUTION, INSURANCE COMPANY,SECURITIES DEALER, INVESTMENT COMPANY AS  DEFINED IN 
THE INVESTMENT COMPANY ACT OF 1940, PENSION OR PROFIT-SHARING TRUST OR
QUALIFIED INSTITUTIONAL BUYER AS DEFINED IN RULE 144A UNDER THE SECURITIES ACT
OF 1933.

 11
 

 

 

	
  

  	
  SIGNATURE PAGE

  
	
  I.

  	
  The total dollar value of Units of Ballistic
  Recovery Systems, Inc. that I wish to subscribe for is:

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  _________________

  	
  X

  	
  $5.44

  	
  =

  	
  $_______________

  
	
   

  	
  (Number of Units, 4,000

  	
   

  	
  (Price per Unit)

  	
   

  	
  (Total Value of Units)

  
	
   

  	
  Minimum purchase.)

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  II.

  	
  Manner in which title is to be held (check the
  correct box):

  

 

	
  

  	
  o

  	
  Individual

  	
  o

  	
  Tenants in Common

  
	
   

  	
  o

  	
  Joint Tenants with
  right of 

  Survivorship

  	
  o

  	
  Corporation

  
	
   

  	
  o

  	
  Partnership

  	
  o

  	
  Trust

  
	
   

  	
  o

  	
  Other (Please
  describe_____________________________)

  
	
   

  	
  o

  	
  IRA (If held in an IRA,
  fill in IRA Custodian information below. 
  IRA Custodian must also sign in item VI.(C).

  

 

____________________________________

Custodian Name

____________________________________

Custodian Street
Address or PO Box

____________________________________

Custodian City
State and Zip Code

____________________________________

Custodian Telephone
Number

 

 

	
  III.

  	
  Name in which title is to be
  held (Please Print—the Securities will be issued in this name):

  
	
   

  	
   

  
	
   

  	
  ___________________________________________________________________

  
	
   

  	
  First Name

  	
  Middle Initial

  	
  Last Name

  

 

 12
 

 

 

	
  IV.

  	
  Addresses

  
	
   

  	
   

  
	
   

  	
  (A)          Address
  of Subscriber’s Domicile and Bona Fide Residence:

  
	
   

  	
   

  
	
   

  	
  ___________________________________________________________________

  
	
   

  	
  Street Address or PO Box

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  ___________________________________________________________________

  
	
   

  	
  City, State and Zip Code

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  ________________________________

  
	
   

  	
  Telephone Number

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  ________________________________

  
	
   

  	
  E-Mail Address

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  (B)          Address
  to Which Correspondence Should be Directed (if different from above):

  
	
   

  	
   

  
	
   

  	
  ___________________________________________________________________

  
	
   

  	
  Street Address or PO Box

  
	
   

  	
   

  
	
   

  	
  ___________________________________________________________________

  
	
   

  	
  City, State and Zip Code

  
	
   

  	
   

  
	
   

  	
  ________________________________

  
	
   

  	
  Telephone Number

  
	
   

  	
   

  
	
   

  	
   

  
	
  V.

  	
  Social Security or Tax ID Number

  
	
   

  	
   

  
	
   

  	
  ________________________________

  	
  ___________________________________

  
	
   

  	
  Tax ID or Social Security Number

  	
  Tax ID or Social Security Number

  
	
   

  	
  (Primary subscriber)

  	
  (Second subscriber, partner, or trustee)

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  

 

 13
 

 

 

	
  VI.

  	
  Signatures:

  
	
   

  	
   

  
	
   

  	
  (A)          Individual
  Signatures for Individuals, IRA’s, Joint Tenants and Tenants in Common

  
	
   

  	
   

  
	
   

  	
  ________________________________

  	
  ___________________________________

  
	
   

  	
  Signature

  	
  Second Signature (if purchasing as joint

  
	
   

  	
   

  	
  tenants or tenants in common, both

  
	
   

  	
  ________________________________

  	
  parties must sign)

  
	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  (B)          Corporate,
  Partnership, Trust and other Entities

  
	
   

  	
   

  	
   

  
	
   

  	
  ________________________________

  	
  ____________________________________

  
	
   

  	
  Print Name of Entity

  	
  Entity Type (Partnership, corporation, trust, etc.)

  
	
   

  	
   

  	
   

  
	
   

  	
  ________________________________

  	
  ____________________________________

  
	
   

  	
  By (signature of person signing)

  	
  Its (title of person signing)

  
	
   

  	
   

  	
   

  
	
   

  	
  ________________________________

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  (C)          IRA
  Custodian (to be signed only if securities are to be held in an IRA)

  
	
   

  	
   

  	
   

  
	
   

  	
  ________________________________

  	
   

  
	
   

  	
  By (signature of authorized person)

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  ____________________________________

  	
   

  
	
   

  	
  Name (print name of person signing)

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  ____________________________________

  	
   

  
	
   

  	
  Its (title of person signing)

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  ________________________________

  	
   

  
	
   

  	
  Date

  	
   

  
	
   

  
	
  This
  Subscription Agreement and Letter of Investment Intent is accepted as of

  	
  ______________________.

  	
   

  
	
   

  	
  (day, month,
  year)

  	
   

  
					

 

	
  

  	
  Ballistic Recovery Systems, Inc.

  
	
   

  	
   

  
	
   

  	
  By

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Its

  	
   

  

 

 14
 

 

CERTIFICATE OF SIGNATORY

(not
to be completed by individuals)

I, ____________________________________________________,
am the ____________________________ of

(printed name of person
signing; first, mi, last name)                                                    (title)

______________________________________________________________ (the
“Entity”).

(name of entity)

I certify that I am
empowered and duly authorized by the Entity to execute and carry out the terms
of the Subscription Agreement and Letter of Investment Intent and to purchase
and hold the Units, and certify further that the Subscription Agreement and
Letter of Investment Intent has been duly and validly executed on behalf of the
Entity and constitutes a legal and binding obligation of the Entity.

IN WITNESS WHEREOF, I have hereto set my hand this
______ day of the month of __________________ in the year _______.

_____________________________________________

(Signature)

 15Exhibit 4.4

 

This Warrant and the
Securities issuable upon exercise of this Warrant have not been registered
under the Securities Act of 1933 (the “Securities Act”) or under any state
securities or “Blue Sky” laws (“Blue Sky Laws”). No transfer, sale, assign­ment,
pledge, hypothecation or other disposition of this Warrant or the Securities
issuable upon exercise of this Warrant or any interest therein may be made
except (a) pursuant to an effective registration statement under the
Securities Act and any applicable Blue Sky Laws or (b) if the Company has been
furnished with an opinion of counsel for the holder, which opinion and counsel
shall be reasonably satisfactory to the Company, to the effect that no
registration is required because of the availability of an exemption from
registration under the Securities Act and applicable Blue Sky laws.

 

 

WARRANT

 

To Purchase                  
Shares of Common Stock

of

BALLISTIC RECOVERY SYSTEMS, INC.

 

EXERCISABLE
ON OR BEFORE, AND VOID AFTER

5:00
P.M. MINNEAPOLIS TIME ON                    ,
200   

 

THIS
CERTIFIES THAT, for good and valuable consideration,                       
(the “Holder”), or registered assigns, 
is entitled to subscribe for and purchase from Ballistic Recovery
Systems, Inc., a Minnesota corporation (the “Company”), at any time after                        ,
200   , to and including                          ,
20      , [THREE YEARS]
                    
(             )
fully paid and non-assessable shares of the Common Stock of the Company at the price
of $2.00 per share (the “Warrant Exercise Price”), subject to the anti-dilution
provisions of this Warrant. 

The
shares that may be acquired upon exercise of this Warrant are referred to
herein as the “Warrant Shares.”  The term
“Common Stock” means the common stock, par value $.01 per share, of the
Company, and shall also include any capital stock of any class of the Company
hereafter authorized which shall not be limited to a fixed sum or percentage in
respect of the rights of the holders thereof to participate in dividends or in
the distribution of assets upon the voluntary or involuntary liquidation,
dissolu­tion, or winding up of the Company. The term “Convertible Securities”
means any stock or other securities convertible into, or exchangeable for,
Common Stock.

This
Warrant is subject to the following provisions, terms and conditions:

1.             Exercise; Transferability.

(a)           The rights represented by this
Warrant may be exercised by the Holder hereof, in whole or in part (but not as
to a fractional share of Common Stock), by written notice of exercise (in the
form attached hereto) delivered to the Company at the principal office of the
Company prior to the expiration of this Warrant and accompanied or preceded by
the surrender of this Warrant along with a check in payment of the Warrant
Exercise Price for such shares.

 

(b)           This Warrant may not be sold,
assigned, hypothecated, or otherwise transferred, other than by will or
pursuant to the operation of law, except in a transaction in compliance with
the provisions of Section 7 hereof.

2.             Exchange and Replacement.
Subject to Sections 1 and 7 hereof, this Warrant is exchangeable upon the
surrender hereof by the Holder to the Company at its office for new Warrants of
like tenor and date representing in the aggregate the right to purchase the
number of Warrant Shares purchasable hereunder, each of such new Warrants to
represent the right to purchase such number of Warrant Shares (not to exceed
the aggregate total number purchasable hereunder) as shall be designated by the
Holder at the time of such surrender. Upon receipt by the Company of evidence
reasonably satisfactory to it of the loss, theft, destruction, or mutilation of
this Warrant, and, in case of loss, theft or destruction, of indemnity or
security reasonably satisfactory to it, and upon surrender and cancellation of
this Warrant, if mutilated, the Company will make and deliver a new Warrant of
like tenor, in lieu of this Warrant. 
This Warrant shall be promptly canceled by the Company upon the
surrender hereof in connection with any exchange or replacement. The Company
shall pay all expenses, taxes (other than stock transfer taxes), and other
charges payable in connection with the preparation, execution, and delivery of
Warrants pursuant to this Section 2.

3.             Issuance
of the Warrant Shares.

(a)           The Company agrees that the shares of
Common Stock purchased upon exercise of this Warrant shall be and are deemed to
be issued to the Holder as of the close of business on the date on which this
Warrant shall have been surrendered and the payment made for such Warrant
Shares as aforesaid. Subject to the provisions of paragraph (b) of this
Section 3, certificates for the Warrant Shares so purchased shall be
delivered to the Holder within a reasonable time, not exceeding fifteen (15)
days after the rights represented by this Warrant shall have been so exercised,
and, unless this Warrant has expired, a new Warrant representing the right to
purchase the number of Warrant Shares, if any, with respect to which this Warrant
shall not then have been exercised shall also be delivered to the Holder within
such time.

(b)           Notwithstanding the foregoing,
however, the Company shall not be required to deliver any certificate for
Warrant Shares upon exercise of this Warrant except in accordance with
exemptions from the applicable securities registration requirements or
registrations under applicable securities laws. Nothing herein, however, shall
obligate the Company to effect registrations under federal or state securities
laws, except as provided in Section 9. If registrations are not in effect
and if exemptions are not available when the Holder seeks to exercise the
Warrant, the Warrant exercise period will be extended, if need be, to prevent
the Warrant from expiring, until such time as either registrations become
effective or exemptions are availa­ble, and the Warrant shall then remain
exercisable for a period of at least 30 calendar days from the date the Company
delivers to the Holder written notice of the availability of such registrations
or exemptions. The Holder agrees to execute such documents and make such
representations, warranties, and agreements as may be required solely to comply
with the exemptions relied upon by the Company, or the registrations made, for
the issuance of the Warrant Shares.

 

4.             Covenants of the Company.
The Company covenants and agrees that all Warrant Shares will, upon issuance,
be duly authorized and issued, fully paid, non-assessable and free from all
taxes, liens and charges with respect to the issue thereof. The Company further
covenants and agrees that during the period within which the rights represented
by this Warrant may be exercised, the Company will at all times have authorized
and reserved for the purpose of issue or transfer upon exercise of the
subscription rights evidenced by this Warrant a sufficient number of shares of
Common Stock to provide for the exercise of the rights represented by this
Warrant.

5.             Anti-Dilution Adjustments.
The provisions of this Warrant are subject to adjustment as provided in this
Section 5.

(a)           The Warrant Exercise Price shall be
adjusted from time to time such that in case the Company shall hereafter:

(i)            pay any dividends on any class of
stock of the Company payable in Common Stock or securities convertible into
Common Stock;

(ii)           subdivide its then outstanding shares
of Common Stock into a greater number of shares; or

(iii)          combine outstanding shares of Common
Stock, by reclassification or otherwise;

then, in any such
event, the Warrant Exercise Price in effect immediately prior to such event
shall (until adjusted again pursuant hereto) be adjusted immediately after such
event to a price (calculated to the nearest full cent) determined by dividing
(A) the number of shares of Common Stock outstanding immediately prior to
such event, multiplied by the then existing Warrant Exercise Price, by
(B) the total number of shares of Common Stock outstanding immediately
after such event (including in each case the maximum number of shares of Common
Stock issuable in respect of any securities convertible into Common Stock), and
the resulting quotient shall be the adjusted Warrant Exercise Price per share.
An adjustment made pursuant to this Subsection shall become effective
immediately after the record date in the case of a dividend or distribution and
shall become effective immediately after the effective date in the case of a
subdivision, combina­tion or reclassification. If, as a result of an adjustment
made pursuant to this Subsection, the Holder of any Warrant thereafter
surrendered for exercise shall become entitled to receive shares of two or more
classes of capital stock or shares of Common Stock and other capital stock of
the Company, the Board of Directors (whose determination shall be conclusive)
shall determine the allocation of the adjusted Warrant Exercise Price between
or among shares of such classes of capital stock or shares of Common Stock and
other capital stock. All calculations under this Subsection shall be made to
the nearest cent or to the nearest 1/100 of a share, as the case may be. In the
event that at any time as a result of an adjustment made pursuant to this Sub­section,
the holder of any Warrant thereafter surrendered for exercise shall become
entitled to receive any shares of the Company other than shares of Common
Stock, thereafter the Warrant Exercise Price of such other shares so receivable
upon exercise of any Warrant shall be subject to adjustment from time to time
in a manner and on terms as nearly equivalent as practicable to the provisions
with respect to Common Stock contained in this Section.

 

(b)           Upon each adjustment of the Warrant
Exercise Price pursuant to Section 5(a) above, the Holder of each Warrant
shall thereafter (until another such adjustment) be entitled to purchase at the
adjusted Warrant Exercise Price the number of shares, calculated to the nearest
full share, obtained by multiplying the number of shares specified in such
Warrant (as adjusted as a result of all adjustments in the Warrant Exercise
Price in effect prior to such adjustment) by the Warrant Exercise Price in
effect prior to such adjustment and dividing the product so obtained by the
adjusted Warrant Exercise Price.

(c)           In case of any consolidation or
merger to which the Company is a party other than a merger or consolidation in
which the Company is the continuing corporation, or in case of any sale or
conveyance to another corporation of the property of the Company as an entirety
or substantially as an entirety, or in the case of any statutory exchange of
securities with another corporation (including any exchange effected in
connection with a merger of a third corporation into the Company), there shall
be no adjustment under Section 5(a) above but the Holder of each Warrant
then outstanding shall have the right thereafter to convert such Warrant into
the kind and amount of shares of stock and other securities and property which
he would have owned or have been entitled to receive immediately after such
consolidation, merger, statutory exchange, sale, or conveyance had such Warrant
been converted immediately prior to the effective date of such consolidation,
merger, statutory exchange, sale, or conveyance and in any such case, if
necessary, appropriate adjustment shall be made in the application of the
provisions set forth in this Section with respect to the rights and interests
thereafter of any Holders of the Warrant, to the end that the provisions set
forth in this Section shall thereafter correspondingly be made applicable, as
nearly as may reasonably be, in relation to any shares of stock and other
securities and property thereafter deliverable on the exercise of the Warrant.
The provisions of this Subsection shall similarly apply to successive
consolidations, mergers, statutory exchanges, sales or conveyances.

(d)           Upon any adjustment of the Warrant
Exercise Price, then and in each such case, the Company shall give written
notice thereof, by First-class mail, postage prepaid, addressed to the Holder
as shown on the books of the Company, which notice shall state the Warrant
Exercise Price resulting from such adjustment and the increase or decrease, if
any, in the number of shares of Common Stock purchasable at such price upon the
exercise of this Warrant, setting forth in reasonable detail the method of
calculation and the facts upon which such calculation is based.

6.             No Voting Rights. This
Warrant shall not entitle the Holder to any voting rights or other rights as a
shareholder of the Company.

7.             Notice
of Transfer of Warrant or Resale of the Warrant Shares.

(a)           Subject to the sale, assignment,
hypothecation, or other transfer restrictions set forth in Section 1
hereof, the Holder, by acceptance hereof, agrees to give written notice to the
Company before transferring this Warrant or transferring any Warrant Shares of such
Holder’s intention to do so, describing briefly the manner of any proposed
transfer. Promptly upon receiving such written notice, the Company shall
present copies thereof to the Company’s counsel and to counsel to the original
purchaser of this Warrant. If in the opinion of each such counsel the proposed
transfer may be effected without registra­tion or qualification 

 

(under any federal
or state securities laws), the Company, as promptly as practicable, shall
notify the Holder of such opinion, whereupon the Holder shall be entitled to
transfer this Warrant or to dispose of Warrant Shares received upon the
previous exercise of this Warrant, all in accordance with the terms of the
notice delivered by the Holder to the Company; provided that an appropriate
legend may be endorsed on this Warrant or the certificates for such Warrant
Shares respecting restrictions upon transfer thereof necessary or advisable in
the opinion of counsel and satisfactory to the Company to prevent further
transfers which would be in violation of Section 5 of the Securities Act
of 1933, as amended (the “1933 Act”) and applicable state securities laws; and
provided further that the prospective transferee or purchaser shall execute
such documents and make such representations, warranties, and agree­ments as
may be required solely to comply with the exemptions relied upon by the Company
for the transfer or disposition of the Warrant or Warrant Shares.

(b)           If in the opinion of either of the
counsel referred to in this Section 7, the proposed transfer or
disposition of this Warrant or such Warrant Shares described in the written
notice given pursuant to this Section 7 may not be effected without
registration or qualification of this Warrant or such Warrant Shares the
Company shall promptly give written notice thereof to the Holder, and the
Holder will limit its activities in respect to such transfer or disposition as,
in the opinion of both such counsel, are permitted by law.

8.             Fractional
Shares.

(a)           Fractional shares shall not be issued
upon the exercise of this Warrant, but in any case where the holder would,
except for the provisions of this Section, be entitled under the terms hereof
to receive a fractional share, the Company shall, upon the exercise of this
Warrant for the largest number of whole shares then called for, pay a sum in
cash equal to the sum of (a) the excess, if any, of the Fair Market Value
of such fractional share over the proportional part of the Warrant Exercise
Price represented by such fractional share, plus (b) the proportional part
of the Warrant Exercise Price represented by such fractional share.

(b)           For purposes of this Section, the
term “Fair Market Value” with respect to shares of Common Stock as of a
particular date (the “Determination Date”) shall mean:

(i)            If the Company’s Common Stock is
traded on an exchange or is quoted on The Nasdaq National Market, then the
average closing or last sale prices, respectively, reported for the ten (10)
business days immediately preceding the Determination Date; 

(ii)           If the Company’s Common Stock is not
traded on an exchange or on The Nasdaq National Market but is traded on The
Nasdaq Small-Cap Market or the local over-the-counter market, then the average
closing bid and asked prices reported for the ten (10) business days immediately
preceding the Determination Date; and

(iii)          If the Company’s Common Stock is not
traded on an exchange, on The Nasdaq National Market, The Nasdaq Small-Cap
Market or on the local over-the-counter market, then the fair market value of
Common Stock as determined in good faith by the Board of Directors of the
Company.

 

9.             Registration
Rights.

(a)           Required Registration.  Pursuant to a Registration Rights Agreement
of even date herewith, the Company shall include the Warrant Shares in the
Registration Statement that it is required to file within forty-five (45) days
of the final closing of the private offering, pursuant to which this Warrant
was issued.   

(a)           Piggyback Registration. If the
Company at any time within two (2) years after complete exercise of this
Warrant, but no more than seven (7) years from the date of this Warrant,
proposes to register under the 1933 Act (except by a Form S-4 or
Form S-8 Registration Statement or any successor forms thereto) or qualify
for a public distribution under Section 3(b) of the 1933 Act, any of its
securities, it will give written notice to all Holders of this Warrant, any
Warrants issued pursuant to Section 2 and/or Section 3(a) hereof, and
any Warrant Shares of its intention to do so and, on the written request of any
such Holder given within twenty (20) days after receipt of any such notice
(which request shall specify the Warrant Shares intended to be sold or disposed
of by such Holder and describe the nature of any proposed sale or other
disposition thereof), the Company will use its best efforts to cause all such
Warrant Shares, the Holders of which shall have requested the registration or
qualification thereof, to be included in such registration statement proposed
to be filed by the Company; provided, however, that if a greater number of
Warrant Shares is offered for participation in the proposed offering than in
the reasonable opinion of the managing underwriter of the proposed offering
(which opinion shall be in writing and delivered to the Holders) can be
accommodated without adversely affecting the proposed offering, then the amount
of Warrant Shares proposed to be offered by such Holders for registration, as
well as the number of securities of any other selling shareholders
participating in the registration, shall not be included or shall be
proportionately reduced to a number deemed satisfactory by the managing
underwriter. With respect to each inclusion of securities in a registration
statement pursuant to this Section 9(a), the selling Holders shall pay the
fees and disbursements of special counsel and accountants for the selling
Holders, and underwriting discounts or commissions and transfer taxes
applicable to the selling Holders’ shares, and the Company shall pay all other
costs and expenses of the registration, including but not limited to all
registration, filing and NASD fees, printing expenses, fees and disbursements
of counsel and accountants for the Company, all internal expenses, and legal
fees and disbursements and other expenses of complying with state securities
laws of any jurisdictions in which the securities to be offered are to be
registered or qualified. The Company need not maintain the effectiveness of any
such registration, qualification, notification or approval, whether or not at the
request of the Holders, more than six (6) months following the effective date
thereof.

(b)           Indemnification. The Company
hereby indemnifies each of the Holders of this Warrant and of any Warrant
Shares, and the officers and directors, if any, who control such Holders,
within the meaning of Section 15 of the 1933 Act, against all losses,
claims, damages, and liabilities caused by (1) any untrue statement or
alleged untrue statement of a material fact contained in any Registration
Statement or Prospectus (and as amended or supplemented if the Company shall
have furnished any amendments thereof or supplements thereto), any Preliminary
Prospectus (not corrected in the final, amended or supplemented prospectus
furnished to such Holders for distribution) or any state securities law
filings; (2) any omission or alleged omission to state therein a material
fact required to be stated therein or necessary to make the statements therein
not misleading except insofar as such losses, claims, damages, or liabilities
are caused by 

 

any untrue
statement or omission contained in information furnished in writing to the
Company by such Holder expressly for use therein; and each such Holder by its
acceptance hereof severally agrees that it will indemnify and hold harmless the
Company, each of its officers who signs such Registration Statement, and each
person, if any, who controls the Company, within the meaning of Section 15
of the 1933 Act, with respect to losses, claims, damages, or liabilities which
are caused by any untrue statement or omission contained in information
furnished in writing to the Company by such Holder expressly for use therein.

(c)           Cooperation. Upon the exercise
of registration rights pursuant hereto, each holder agrees to supply the
Company with such information as may be required by the Company to register or
qualify the shares to be registered.

10.           Additional
Right to Convert Warrant.

(a)           The holder of this Warrant shall have
the right to require the Company to convert this Warrant (the “Conversion Right”)
at any time after it is exercisable, but prior to its expiration into shares of
Common Stock as provided for in this Section 10. Upon exercise of the
Conversion Right, the Company shall deliver to the holder (without payment by
the holder of any Warrant Exercise Price) that number of shares of Company
Common Stock equal to the quotient obtained by dividing (i) the value of
the Warrant at the time the Conversion Right is exercised (determined by
subtracting the aggregate Warrant Exercise Price for the Warrant Shares in
effect immediately prior to the exercise of the Conversion Right from the
aggregate Fair Market Value for the Warrant Shares immediately prior to the
exercise of the Conversion Right) by (ii) the Fair Market Value of one
share of Common Stock immediately prior to the exercise of the Conversion
Right.

(b)           The Conversion Right may be exercised
by the holder, at any time or from time to time, prior to its expiration, on
any business day by delivering a written notice in the form attached hereto (the
“Conversion Notice”) to the Company at the offices of the Company exercising
the Conversion Right and specifying (i) the total number of shares of
Common Stock the Holder will purchase pursuant to such conversion and
(ii) a place and date not less than one or more than 20 business days from
the date of the Conversion Notice for the closing of such purchase.

(c)           At any closing under
Section 10(b) hereof, (i) the Holder will surrender the Warrant, (ii)
the Company will deliver to the Holder a certificate or certificates for the
number of shares of Common Stock issuable upon such conversion, together with
cash, in lieu of any fraction of a share, and (iii) the Company will
deliver to the Holder a new warrant representing the number of shares, if any,
with respect to which the Warrant shall not have been exercised.

(d)           For purposes of this section, “Fair
Market Value” of a share of Common Stock as of a particular date shall be
determined as provided in Section 8(b) above.

 

IN WITNESS WHEREOF, <ISSUER> has caused this
Warrant to be signed by its duly authorized officer and this Warrant to be
dated                    ,
200   .

	
  

  	
   

  	
  BALLISTIC RECOVERY SYSTEMS, INC.

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
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  Its

  	
   

  

 

 

 

SUBSCRIPTION FORM

(To be signed upon exercise of
Warrant)

 

 

The
undersigned, the holder of the within Warrant, hereby irrevocably elects to
exercise the purchase right represented by such Warrant for, and to purchase
thereunder,                          
                          
of the shares of Common Stock of BALLISTIC RECOVERY SYSTEMS, INC to which such
Warrant relates and herewith makes payment of $                               
therefor in cash or by certified check and requests that the certificate for
such shares be issued in the name of, and be delivered to,                                      ,
the address for which is set forth below the signature of the undersigned.

	
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  Social Security or Tax Ident. No.

  

 

 

CONVERSION NOTICE

(To be signed upon exercise of
Warrant pursuant to Section 10)

 

 

The
undersigned hereby irrevocably elects to exercise the conversion right provided
in Section 10 of the within Warrant for, and to acquire thereunder,                                          
shares of Common Stock. If said number of shares shall not be all the shares
purchasable under the within Warrant, a new Warrant is to be issued in the name
of said undersigned for the balance remaining of the shares purchasable
thereunder rounded up to the next higher number of shares.

Please
issue a certificate or certificates for such Common Stock in the name of:                   
                                               .

	
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  Social Security or Tax Ident. No.

  

 

 

 

ASSIGNMENT FORM

(To be signed upon authorized
transfer of Warrant)

 

 

FOR
VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers unto                                           
the right to purchase
                     
shares of Common Stock of <ISSUER> to which the within Warrant relates and
appoints
                         
attorney, to transfer said right on the books of                                      
with full power of substitution in the premises.

	
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  Social Security or Tax Ident. No.

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