Document:

exv10w21

 

EXHIBIT 10.21

THIS NOTE HAS NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”).
IT MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED, HYPOTHECATED OR OTHERWISE TRANSFERRED IN THE ABSENCE
OF SUCH REGISTRATION OR EVIDENCE SATISFACTORY TO THE PAYOR OF AN APPLICABLE EXEMPTION UNDER THE ACT
OR COMPLIANCE WITH RULE 144 UNDER SUCH ACT.

PROMISSORY NOTE

			
	$___
	 	Promissory Note No. ___
	 
	 	June 16, 2003
	 
	 	as amended December 9, 2003

     FOR VALUE RECEIVED, the undersigned, Restore Medical, Inc. (“Payor”), hereby promises to pay
                                                             (“Payee”) the sum of                 
                         DOLLARS ($                    ) in
lawful currency of the United States of America at the demand of the Payee at any time on or after
December 31, 2003. This Note shall bear interest at a rate of 12% per annum, commencing as of June
16, 2003, payable together with principal at maturity. Payment shall be credited first to Costs
(as defined below), if any, then to accrued interest due and payable, and any remainder shall be
applied to principal.

     This Note is issued pursuant to, and is entitled to the benefits of the provisions of that
certain Bridge Loan Agreement, dated as of June 16, 2003, as amended as of December 9, 2003 (the
“Bridge Loan Agreement”) between the Payor, the Payee and the others parties thereto; but neither
this reference to such Bridge Loan Agreement nor any provision thereof shall affect or impair the
absolute and unconditional obligation of the maker of this Note to pay the principal hereof and
interest hereon as herein provided. Any capitalized term not otherwise defined herein shall have
the meaning ascribed to such term in the Bridge Loan Agreement.

     The holder hereof is entitled to all of the benefits and subject to all of the obligations
provided for in the Bridge Loan Agreement, including conversion hereof as provided under Section
7.1 thereof, and repayment in the event of (a) any liquidation, dissolution or winding up of the
Company, whether voluntary or involuntary, (b) any consolidation, merger or sale of all or
substantially all of the assets of the Company, or (c) any transfer of more than fifty percent
(50%) of the voting power of the Company as provided under Section 7.5 thereof. Reference is made
to the Bridge Loan Agreement for a statement of the terms and conditions under which this
indebtedness was incurred (including conversion, waiver, etc.) and the Events of Default under
which the promissory note may come due. The provisions of the Bridge Loan Agreement are
incorporated by reference herein with the same force and effect as if fully set forth herein.

     This Note shall, upon an Event of Default (as defined in the Bridge Loan Agreement), become
immediately due and payable without any notice or other action on the part of the holder hereof, as
specified in the Bridge Loan Agreement. This Note may not be prepaid in whole or in part without
the consent of the Payee.

 

 

     This Note is secured under a security agreement (the “Security Agreement”) between the Payor
and the Payee dated as of June 16, 2003, attached hereto as Exhibit A. Reference is hereby made to
the Security Agreement for a description of the nature and extent of the security for this Note and
the rights with respect to such security of the holder of this Note.

     The Company hereby agrees, subject only to any limitation imposed by applicable law, to pay
all expenses, including reasonable attorneys’ fees and legal expenses, incurred by the holder of
this Note (“Costs”) in endeavoring to collect any amounts payable hereunder which are not paid when
due, whether by declaration or otherwise. The Company agrees that any delay on the part of the
holder in exercising any rights hereunder will not operate as a waiver of such rights. The holder
of this Note shall not by any act, delay, omission or otherwise be deemed to have waived any of its
rights or remedies, and no waiver of any kind shall be valid unless in writing and signed by the
party or parties waiving such rights or remedies.

     This Note has been acquired for investment and has not been registered under the Act. This
Note may not be sold, offered for sale, pledged, hypothecated or otherwise transferred in the
absence of such registration or evidence satisfactory to Payor of an applicable exemption therefrom
under the Act or compliance with Rule 144 under the Act.

     This Note shall be deemed to have been made under and shall be governed by the laws of the
State of Minnesota without giving effect to conflict of laws rules and none of its terms or
provisions may be waived, altered, modified or amended except as Payor or Payee may consent thereto
in writing.

     The Payor and all endorsers of this Note each hereby waives presentment, demand, notice of
nonpayment, protest and all other demands and notices in connection with the delivery, acceptance,
performance or enforcement of this Note.

     Amendment. This Note is intended to amend by substitution the Note dated as of June 16, 2003,
made by the Company in favor of Payee.

     IN WITNESS WHEREOF, Payor has executed and delivered this Note to Payee as of the date first
written above.

	 	 	 	 	 
	 
	 	 	 	 
	 	 	RESTORE MEDICAL, INC.
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	By:	 	 
	 

	 	 	 	 
	 

	 	 	 	Name: Susan L. Critzer
	 

	 	 	 	Title: President and Chief Executive Officerexv10w22

 

EXHIBIT 10.22

THIS WARRANT AND THE SECURITIES ISSUABLE UPON EXERCISE HEREOF HAVE NOT BEEN REGISTERED UNDER
THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”). THIS WARRANT AND SUCH SECURITIES MAY NOT BE
SOLD, OFFERED FOR SALE, PLEDGED, HYPOTHECATED, OR OTHERWISE TRANSFERRED IN THE ABSENCE OF SUCH
REGISTRATION OR EVIDENCE SATISFACTORY TO THE COMPANY OF AN APPLICABLE EXEMPTION FROM REGISTRATION
UNDER THE ACT OR COMPLIANCE WITH RULE 144 UNDER SUCH ACT. THE TRANSFER OF THIS WARRANT IS FURTHER
RESTRICTED AS PROVIDED HEREIN.

AMENDED AND RESTATED

COMMON STOCK WARRANT

			
	Warrant No. ___
	 	December 9, 2003

WARRANT TO PURCHASE

_______ SHARES OF COMMON STOCK

OF

RESTORE MEDICAL, INC.

This certifies that as of the date written above (the “Warrant Issue Date”), for value received,
                                         (“Holder”) is entitled, subject to the terms set forth below, to purchase
from Restore Medical, Inc., a Minnesota corporation (the “Company”), such number of fully paid and
non-assessable shares of Common Stock, par value $0.01, of the Company (“Common Stock”), as set
forth in Section 2 hereof, (subject to adjustment as provided in Section 10 hereof) upon surrender
hereof, at the principal office of the Company referred to below, with the Notice of Exercise
attached hereto duly executed, and simultaneous payment thereof in lawful money of the United
States or otherwise as hereinafter provided, at the Exercise Price as set forth in Section 2 below.
The number, character and Exercise Price of such shares of Common Stock are subject to adjustment
as provided below. The term “Warrant” as used herein, shall include this Warrant and any warrants
delivered in substitution or exchange therefor as provided herein.

     This Warrant is being issued in connection with a bridge financing of the Company pursuant to
a Bridge Loan Agreement, as amended (the “Bridge Loan Agreement”) and related Promissory Note, as
amended (the “Note”), each dated as of the date hereof (the “Bridge Financing”). Capitalized terms
used herein but not defined herein shall have the meaning set forth in the Bridge Loan Agreement.

1. Term of Warrant. Subject to the terms and conditions set forth herein, this Warrant shall
be exercisable in whole or in part; provided however that notwithstanding anything to the contrary
herein, this Warrant shall expire upon the earlier of (a) June 16, 2011 and (b) the closing of (i)
any consolidation or merger of the Company with or into another entity (except a consolidation

 

 

or merger in which the holders of capital stock of the Company immediately prior to such consolidation
or merger continue to hold at least 50% of the voting power of the capital stock of the Company or
the surviving or acquiring entity) or (ii) the sale, transfer or other disposition of all or
substantially all of the assets of the Company (any one of which, a “Corporate Transaction”), and
shall be void thereafter. In the event of a Corporate Transaction, the Company shall mail notice
of such Corporate Transaction to the Holder at least twenty (20) days prior to the consummation of
such Corporate Transaction.

2. Exercise Price and Number of Shares.

(A) The Exercise Price at which this Warrant may be exercised shall be $0.01 per share of
Common Stock, as adjusted from time to time pursuant to Section 10 hereof.

(B) The number of shares of Common Stock initially issuable upon exercise of this Warrant
shall be 46,412.

3. Exercise of Warrant.

(A) Manner of Exercise. The purchase rights represented by this Warrant are
exercisable by the Holder in whole or in part, at any time, or from time to time, during the
term hereof as described in Section 1 above, by the surrender of this Warrant and the Notice
of Exercise attached hereto duly completed and executed on behalf of the Holder, at the
office of the Company (or such other office or agency of the Company as it may designate by
notice in writing to the Holder at the address of the Holder appearing on the books of the
Company), together with payment of an amount equal to the Exercise Price multiplied by the
number of shares then being purchased, at Holder’s option in cash, by bank cashier’s check
or certified check (or other check acceptable to the Company) or by wire transfer to a bank
account designated by the Company for that purpose by written notice to Holder.

Notwithstanding the provisions of Section 1, if the Holder has not exercised this Warrant
prior to the closing of a Corporate Transaction, this Warrant shall automatically be deemed
to be exercised in full in the manner set forth in Section 3(C), without any further action
on behalf of the Holder, immediately prior to such closing.

(B) Effective Time of Exercise. This Warrant shall be deemed to have been exercised
immediately prior to the close of business on the date of its surrender for exercise as
provided above, and the Holder entitled to receive the shares of Common Stock issuable upon
such exercise shall be treated for all purposes as the holder of record of such shares as of
the close of business on such date. As promptly as practicable on or after such date and in
any event within ten (10) days thereafter, the Company at its expense shall issue and
deliver to the Holder a certificate or certificates in the name of the Holder or as such
Holder may direct (upon payment by such Holder of any applicable transfer taxes) for the
number of shares issuable upon such exercise. In the event that this Warrant is exercised
in part, the Company at its expense will execute and deliver a new warrant of like tenor
exercisable for the number of shares then remaining for which this warrant may then be
exercised.

 

 

(C) Net Issue Exercise.

          (i) In lieu of exercising this Warrant in the manner provided above in Section 3(A),
the Holder may elect to receive shares equal to the value of this Warrant (or portion
thereof being exercised) by surrender of this Warrant at the principal office of the Company
together with notice of such election on the Notice of Exercise form attached hereto duly
executed by such Holder or such Holder’s duly authorized attorney, in which event the
Company shall issue to such Holder a number of shares computed using the following formula:

	 	 	 	 	 
	 	 	X=Y(A-B)
	 

	 	 	 	A
	 
	 	 	 	 
	Where     

	 	X =
	 	The number of shares to be issued to the Holder
	 
	 	 	 	 
	 

	 	Y =
	 	The number of shares purchasable under this Warrant or,
if only a portion of the Warrant is being exercised, the
portion of the Warrant being cancelled (at the date of
such calculation)
	 
	 	 	 	 
	 

	 	A =
	 	The fair market value of one share of Warrant stock (at
the date of such calculation)
	 
	 	 	 	 
	 

	 	B =
	 	The Exercise Price (as adjusted to the date of such
calculation)

          (ii) For purposes of this Section 3(C), the fair market value of one share of Common
Stock on the date of calculation shall mean:

               (A) if the exercise is in connection with an initial public offering of the Company’s
Common Stock, and if the Company’s Registration Statement relating to such public offering
has been declared effective by the Securities and Exchange Commission, then the fair market
value of Common Stock shall be the initial “Price to Public” per share specified in the
final prospectus with respect to the offering;

               (B) if this Warrant is exercised after, and not in connection with, the Company’s
initial public offering, and if the Company’s Common Stock is traded on a securities
exchange or The Nasdaq Stock Market or actively traded over-the-counter:

                    (1) if the Company’s Common Stock is traded on a securities exchange or The Nasdaq
Stock Market, the fair market value shall be deemed
to be the average of the closing prices over a thirty (30) day period ending three days
before date of calculation; or

                    (2) if the Company’s Common Stock is actively traded over-the-counter, the fair market
value shall be deemed to be the average of the closing

 

 

bid or sales price (whichever is
applicable) over the thirty (30) day period ending three days before the date of
calculation; or

          (C) if neither (A) nor (B) is applicable, the fair market value shall be at the highest
price per share which the Company could obtain on the date of calculation from a willing
buyer (not a current employee or director) for shares of Common Stock sold by the Company,
from authorized but unissued shares, as determined in good faith by the Board of Directors
and agreed to by the Holder.

4. No Fractional Shares or Scrip. No fractional shares or scrip representing fractional shares
shall be issued upon the exercise of this Warrant. In lieu of any fractional share to which the
Holder would otherwise be entitled, the Company shall make a cash payment equal to the Exercise
Price multiplied by such fraction.

5. Replacement of Warrant. On receipt of evidence reasonably satisfactory to the Company of
loss, theft, destruction or mutilation of this Warrant and, in the case of loss, theft or
destruction, on delivery of an indemnity bond or other security in an amount reasonably
satisfactory as sufficient security, or in the case of mutilation, on surrender and cancellation of
this Warrant, the Company at its expense shall execute and deliver, in lieu of this Warrant, a new
warrant of like tenor and amount.

6. Rights of Stockholders.

(A) Limitations on Rights of Warrant. Subject to Section 10 below, the Holder shall
not be entitled to vote or receive dividends or be deemed the holder of Common Stock or any
other securities of the Company that may at any time be issuable on the exercise hereof for
any purpose, nor shall anything contained herein be construed to confer upon the Holder, as
such, any of the rights of a stockholder of the Company or any right to vote for the
election of directors or upon any matter submitted to stockholders at any meeting thereof,
or to give or withhold consent to any corporate action (whether upon any recapitalization,
issuance of stock, reclassification of stock, change of par value, or change of stock to no
par value, consolidation, merger, conveyance or otherwise) or to receive notice of meetings,
or to receive dividends or subscription rights or otherwise until the Warrant shall have
been exercised as provided herein.

(B) Notices of Certain Transactions. In case:

(a) the Company shall take a record of the holders of its Common Stock and/or
preferred stock (or other stock or securities at the time deliverable upon the
exercise of this Warrant) for the purpose of entitling or enabling them to
receive any dividend or other distribution, or to receive any right to subscribe
for or purchase any shares of stock of any class or any other securities, or to
receive any other right, to subscribe for or purchase any shares of stock of any
class or any other securities, or to receive any other right, or

(b) of any capital reorganization of the Company, any reclassification of the
capital stock of the Company, any consolidation or merger of the Company, any
consolidation or merger of the Company with or into another corporation

 

 

(other than a consolidation or merger in which the Company is the surviving entity), or
any transfer of all or substantially all of the assets of the Company, or

(c) of the voluntary or involuntary dissolution, liquidation or winding-up of
the Company, or

(d) of the initial public offering of the Company,

then, and in each such case, the Company will mail or cause to be mailed to the Holder a notice
specifying, as the case may be, (i) the date on which a record is to be taken for the purpose of
such dividend, distribution, or right, and stating the amount and character of such dividend,
distribution or right, or (ii) the effective date on which such reorganization, reclassification,
consolidation, merger, transfer, dissolution, liquidation, winding-up, redemption or conversion is
to take place, and the time, if any is to be fixed, as of which the holders of record of Common
Stock (or other stock or securities at the time deliverable upon such reorganization,
reclassification, consolidation, merger, transfer, dissolution, liquidation, winding-up, redemption
or conversion) are to be determined. Such notice shall be mailed at least twenty (20) days prior
to the record date or effective date for the event specified in such notice.

7. Transfer of Warrant.

(A) Non-transferability of Warrant. This Warrant may be transferred, in whole or
part, without consent of the Company, only to an Affiliate of the Holder and to and from the
beneficial owner hereof and any nominee from time to time acting as custodian for the
beneficial owner hereof, in each case upon receipt of a representation reasonably
satisfactory to the Company from the proposed transferee that it is an “accredited investor”
as such term is defined in Rule 501 of Regulation D promulgated under the Securities Act of
1933 and is taking this Warrant for his, her or its own account, for investment and not with
a view towards distribution or resale. This Warrant may also be transferred, in whole or
part, to a non-Affiliate of the Holder with the prior written consent of the Company. For
purposes hereof, the term “Affiliate” shall mean any parent, subsidiary, stockholder,
partner, retired partner or member of the Holder, and if
the beneficial owner of this Warrant is an individual, any spouse, child, heir, legatee,
executor or other personal representative of such individual. Any such transfer shall be
made only in compliance with all applicable federal and state securities laws.

(B) Exchange of Warrant Upon Transfer. On the surrender of this Warrant in
connection with a transfer pursuant to the terms of Section 7(A), the Company, at its
expense, shall issue to the successor a new warrant or warrants of like tenor, in the name
of the assignees, successors or heirs, who shall thereupon become the Holder(s) thereof, and
shall be subject to all of the terms and conditions thereof.

(C) Compliance With Securities Laws.

(1) The Holder of this Warrant, or if the Holder is a custodian, the beneficial
owner of this Warrant, by acceptance hereof, acknowledges that this Warrant and the
shares of Common Stock to be issued upon exercise hereof are being acquired

 

 

solely for the Holder’s (or beneficial owner’s) own account and not as a nominee for any
other party, and for investment, and that the Holder will not offer, sell or
otherwise dispose of this Warrant or any shares of Common Stock to be issued upon
exercise hereof except under circumstances that will not result in a violation of
any federal or state securities laws. Upon exercise of the Warrant (other than
pursuant to the net exercise provision of Section 3(C)), the Holder shall as a
condition to such exercise, if reasonably requested by the Company, confirm in
writing, in a form reasonably satisfactory to the Company that the shares of Common
Stock so purchased are being acquired solely for the Holder’s own account and not as
a nominee for any other party, for investment, and not with a view toward
distribution or resale.

(2) All shares of Common Stock issued upon exercise hereof may be stamped or
imprinted with a legend in substantially the following form (in addition to any
legend required by state securities laws), so long as such legend is required by
applicable law:

THE SECURITIES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF
1933, AS AMENDED (THE “ACT”). THESE SECURITIES MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED,
HYPOTHECATED, OR OTHERWISE TRANSFERRED IN THE ABSENCE OF SUCH REGISTRATION OR EVIDENCE SATISFACTORY
TO THE COMPANY OF AN APPLICABLE EXEMPTION FROM REGISTRATION UNDER THE ACT OR COMPLIANCE WITH RULE
144 UNDER SUCH ACT.

If the legend is no longer required (as evidenced by a legal opinion for the Holder or the Company
or by evidence otherwise reasonably satisfactory to the Company), the Company will promptly remove
such legend.

8. Reservation of Stock. During the term of this Warrant, the Company will at all times have
authorized and reserved for the purpose of issuance upon exercise of this Warrant, a sufficient
number of shares of the Company’s Common Stock to provide for the exercise of this Warrant. If at any time
during the term of this Warrant the number of authorized but unissued shares of Common Stock shall
not be sufficient to permit exercise of this Warrant, the Company will take such corporate action
as may, in the opinion of its counsel, be necessary to increase its authorized but unissued shares
of Common Stock to such number of shares as shall be sufficient for such purposes. All shares that
may be issued upon the exercise of rights represented by this Warrant upon issuance, will be fully
paid and non-assessable, free from all taxes, liens and charges in respect of the issuance thereof.

9. Amendments. This Warrant and any term hereof may be changed, waived, discharged or
terminated only in accordance with the terms of the Bridge Loan Agreement.

10. Special Provision.

(A) Reclassification. If the Company at any time while this Warrant, or any portion
thereof, remains outstanding and unexpired, by reclassification of securities or otherwise,

 

 

shall change any of the securities as to which purchase rights under this Warrant exist into
the same or a different number of securities of any other class or classes, this Warrant
shall thereafter represent the right to acquire such number and kind of securities as would
have been issuable as a result of such change with respect to the securities that were
subject to the purchase rights under this Warrant immediately prior to such reclassification
or other change and the Exercise Price therefore shall be appropriately adjusted, all
subject to further adjustment as provided in this Section 10.

(B) Split, Subdivision, Reverse Split or Combination or Shares. If the Company at
any time while this Warrant, or any portion thereof, remains outstanding and unexpired shall
issue additional shares of its Common Stock as a dividend with respect to any shares of its
Common Stock, or split, subdivide, reverse split or combine the securities as to which
purchase rights under the Warrant exist, into a different number of securities of the same
class, the Exercise Price per share for such securities shall be proportionately decreased
in the case of a stock dividend, split or subdivision or proportionately increased in the
case of a combination or reverse split and the number of shares which the Holder hereof
shall be entitled to receive upon exercise shall be correspondingly appropriately adjusted.

(C) Certificate as to Adjustments. Upon the occurrence of each adjustment or
readjustment pursuant to this Section 10, the Company at its expense shall promptly compute
such adjustment or readjustment in accordance with the terms hereof and promptly mail to
each Holder of this Warrant a certification of the Company’s Chief Financial Officer setting
forth in detail (i) the facts requiring such adjustment, (ii) the Exercise Price after such
adjustment and (iii) the kind and amount of stock or other securities or property into which
this Warrant shall be exercisable after such adjustment.

11. No Impairment. The Company will not avoid or seek to avoid the observance or performance of any of the
terms to be observed or performed hereunder by the Company, but will at all times in good faith use
its best efforts to carry out all of the provisions of this Warrant, including without limitation,
the provisions of Section 10, and to take all such action as may be necessary or appropriate in
order to protect the exercise rights of the Holder against impairment.

12. Miscellaneous.

(A) Notices. Any notice required or permitted under this Warrant shall be in
writing sent by hand or certified or registered, first class mail, return receipt requested,
to:

	 	 	 	 	 
	 

	 	Holder:
	 	At the address set forth for the original Holder hereof in Schedule A to the Bridge
Loan Agreement.
	 
	 	 	 	 
	 

	 	Company:
	 	Restore Medical, Inc.
	 

	 	 	 	2800 Patton Drive
	 

	 	 	 	St. Paul, MN 55113
	 

	 	 	 	Attention: President and Chief Executive Officer

or to such other address of which either party shall notify the other by similar notice.

 

 

(B) Governing Law. This Warrant shall be governed by and construed in accordance
with the laws of the State of Minnesota, without regard to its conflicts of law provisions.

(C) Successors. This Warrant shall be binding upon any successor(s) or assign(s) of
the Company.

(D) Headings. The headings used in this Warrant are used for convenience only and
are not to be considered in construing or interpreting this Warrant.

     (E) Saturdays, Sundays, and Holidays. If the expiration date of this Warrant falls
on a Saturday, Sunday or a Holiday, the term of this Warrant shall be extended to the next
business day. “Holiday” as used herein means any day on which the principal office of the
Company is officially closed or which is a bank closing day for banks in New York or in the
Federal Reserve System. “Close of business” as used herein means close of business in the
State of New York.

13. Amendment. This warrant is intended to amend by substitution the Common Stock Warrant
dated as of June 16, 2003, made by the Company in favor of Holder.

 

 

IN WITNESS WHEREOF, Restore Medical, Inc. has caused this Warrant to be executed by its officer
thereunto duly authorized.

Dated: December 9, 2003

	 	 	 	 	 
	 	 	RESTORE MEDICAL, INC.
	 
	 	 	 	 
	 
	 	 	 	 
	 

	 	By	 	 
	 

	 	 	 	 
	 

	 	 	 	Name: Susan L. Critzer
	 

	 	 	 	Title: President and Chief Executive
	 

	 	 	 	          Officer

 

 

NOTICE OF EXERCISE

To Restore Medical, Inc.:

1. The
undersigned hereby elects to purchase                      shares of Common Stock of Restore
Medical, Inc., par value $0.01, pursuant to the terms of the attached Warrant:

[Check Appropriate Box]

	 	 	 	 	 
	o

	 	a.
	 	Tenders herewith payment of the exercise price for such shares in full.
	 
	 	 	 	 
	o

	 	b.
	 	Elects to exercise this Warrant for                      shares purchasable pursuant to the
Warrant pursuant to the net exercise provisions of Section 3(C).

2. If the undersigned is exercising this Warrant pursuant to 1 (a) above, the undersigned hereby
confirms and acknowledges that the shares of the Common Stock to be issued upon exercise thereof
are being acquired solely for the account of the undersigned and not as a nominee for any other
party, and for investment and not with a view towards distribution, and that the undersigned will
not offer, sell or otherwise dispose of any such shares of Common Stock except under circumstances
that will not result in a violation of the Securities Act of 1933, as amended, or any state
securities laws.

3. Please issue a certificate or certificates representing said shares of the Common Stock in the
name of the undersigned or in such other name as is specified below.

4. Please issue a new Warrant for the unexercised portion (if any) of the attached Warrant.

	 	 	 
	 
	 	 
	 

	 	 
	Signature

	 	Date
	 
	 	 
	 
	 	 
	 

Name                                                             [PLEASE PRINT]

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