Document:

ex_143696.htm

Exhibit 10.3

 

THIS WARRANT AND THE SHARES ISSUABLE HEREUNDER HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”), OR THE SECURITIES LAWS OF ANY STATE AND, EXCEPT AS SET FORTH IN SECTION 5.3 BELOW, MAY NOT BE OFFERED, SOLD, PLEDGED OR OTHERWISE TRANSFERRED UNLESS AND UNTIL REGISTERED UNDER SAID ACT AND LAWS OR, IN THE OPINION OF LEGAL COUNSEL IN FORM AND SUBSTANCE SATISFACTORY TO THE COMPANY, SUCH OFFER, SALE, PLEDGE OR OTHER TRANSFER IS EXEMPT FROM SUCH REGISTRATION.

 

ALLIQUA BIOMEDICAL, INC.

 

WARRANT TO PURCHASE STOCK

 

	
			Number of Shares:

				
			[___]

			
	
			Type/Series of Stock:

				
			Common Stock

			
	
			Warrant Price:

				
			$6.34 per share

			
	
			Issue Date:

				
			May 3, 2019

			
	
			Expiration Date:

				
			November 24, 2025 (See also Section 5.1(b))

			
	
			Credit Facility:

				
			This Warrant to Purchase Stock (“Warrant”) is issued in connection with that certain Loan and Security Agreement, dated November 24, 2015, among Oxford Finance LLC (“Oxford”), as Lender and Collateral Agent, the Lenders from time to time party thereto, and the Company (as modified, amended and/or restated from time to time, the “Loan Agreement”).

			

 

THIS WARRANT CERTIFIES THAT, for good and valuable consideration, Oxford (together with any successor or permitted assignee or transferee of this Warrant or of any shares issued upon exercise hereof, “Holder”) is entitled to purchase the number of fully paid and non-assessable shares (the “Shares”) of the above-stated Type/Series of Stock (the “Class”) of the above-named company ALLIQUA BIOMEDICAL, INC., a Delaware corporation (which will be renamed ADYNXX, INC. on or about the date hereof) (the “Company”) at the above-stated Warrant Price, all as set forth above and as adjusted pursuant to Section 2 of this Warrant, subject to the provisions and upon the terms and conditions set forth in this Warrant. This Warrant is issued in lieu of that certain Warrant to Purchase Stock issued on November 24, 2015 by Adynxx, Inc., a Delaware corporation, to Oxford, exercisable for [___] shares of Series A Preferred Stock at price per share of $0.2276 (“Old Warrant”), and upon Company’s execution and delivery of this Warrant and Oxford’s acceptance of the same, Old Warrant shall be declared null and void.

 

SECTION 1.     EXERCISE.

 

1.1     Method of Exercise. Holder may at any time and from time to time, during the period commencing on the Issue Date and ending at 6:00 p.m. Pacific Time on the Expiration Date, exercise this Warrant, in whole or in part, by delivering to the Company at the principal executive office of the Company (or such other office or agency of the Company as it may designate by notice in writing to Holder at the address of Holder appearing on the books of the Company) the original of this Warrant together with a duly executed Notice of Exercise in substantially the form attached hereto as Appendix 1 (a “Notice of Exercise”) and, unless Holder is exercising this Warrant pursuant to a cashless exercise as set forth in Section 1.2, tendering payment of the aggregate Warrant Price for the Shares being purchased by cash, check, wire transfer of same-day funds (to an account designated by the Company), cancellation of indebtedness of the Company to Holder, or other form of payment acceptable to the Company.

 

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1.2     Cashless Exercise. On any exercise of this Warrant, in lieu of payment of the aggregate Warrant Price in the manner as specified in Section 1.1 above, but otherwise in accordance with the requirements of Section 1.1, Holder may elect to receive Shares equal to the value of this Warrant, or portion hereof as to which this Warrant is being exercised. Thereupon, the Company shall issue to Holder such number of fully paid and non-assessable Shares as are computed using the following formula:

 

	
			X

				
			=

				
			Y (A – B)

			
	 	 	
			A

			

where:

 

	 	
			X =

				
			the number of Shares to be issued to Holder;

			

 

	 	
			Y =

				
			the number of Shares with respect to which this Warrant is being exercised (inclusive of the Shares surrendered to the Company in payment of the aggregate Warrant Price);

			

 

	 	
			A =

				
			the fair market value (as determined pursuant to Section 1.3 below) of one Share; and

			

 

	 	
			B =

				
			the Warrant Price.

			

 

1.3     Fair Market Value. If the Company’s common stock is then traded or quoted on a nationally recognized securities exchange, inter-dealer quotation system or over-the-counter market (a “Trading Market”) and the Class is common stock, the fair market value of a Share shall be the closing price or last sale price of a share of common stock reported for the Business Day immediately before the date on which Holder delivers this Warrant together with its Notice of Exercise to the Company. If the Company’s common stock is then traded in a Trading Market and the Class is a series of the Company’s convertible preferred stock, the fair market value of a Share shall be the closing price or last sale price of a share of the Company’s common stock reported for the Business Day immediately before the date on which Holder delivers this Warrant together with its Notice of Exercise to the Company multiplied by the number of shares of the Company’s common stock into which a Share is then convertible. If the Company’s common stock is not traded in a Trading Market, the Board of Directors of the Company shall determine the fair market value of a Share in its reasonable good faith judgment.

 

1.4     Delivery of Certificate and New Warrant. Within a reasonable time after Holder exercises this Warrant in the manner set forth in Section 1.1 or 1.2 above, the Company shall deliver to Holder a certificate representing the Shares issued to Holder upon such exercise and, if this Warrant has not been fully exercised and has not expired, a new warrant of like tenor representing the Shares not so acquired.

 

1.5     Replacement of Warrant. On receipt of evidence reasonably satisfactory to the Company of the loss, theft, destruction or mutilation of the original copy of this Warrant and, in the case of loss, theft or destruction, on delivery of an indemnity agreement reasonably satisfactory in form, substance and amount to the Company or, in the case of mutilation, on surrender of the original copy of this Warrant to the Company for cancellation, the Company shall, within a reasonable time, execute and deliver to Holder, in lieu of this Warrant, a new warrant of like tenor and amount.

 

1.6     Treatment of Warrant Upon Acquisition of Company.

 

(a)     For the purpose of this Warrant, “Acquisition” means any transaction or series of related transactions involving: (i) the sale, lease, exclusive license, or other disposition of all or substantially all of the assets of the Company (ii) any merger or consolidation of the Company into or with another person or entity (other than a merger or consolidation effected exclusively to change the Company’s domicile), or any other corporate reorganization, in which the stockholders of the Company in their capacity as such immediately prior to such merger, consolidation or reorganization, own less than a majority of the Company’s (or the surviving or successor entity’s) outstanding voting power immediately after such merger, consolidation or reorganization (or, if such Company stockholders beneficially own a majority of the outstanding voting power of the surviving or successor entity as of immediately after such merger, consolidation or reorganization, such surviving or successor entity is not the Company); or (iii) any sale or other transfer by the stockholders of the Company of shares representing at least a majority of the Company’s then-total outstanding combined voting power.

 

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(b)     In the event of an Acquisition in which the consideration to be received by the Company’s stockholders consists solely of cash, solely of Marketable Securities or a combination of cash and Marketable Securities (a “Cash/Public Acquisition”), either (i) Holder shall exercise this Warrant pursuant to Section 1.1 and/or 1.2 and such exercise will be deemed effective immediately prior to and contingent upon the consummation of such Acquisition or (ii) if Holder elects not to exercise the Warrant, this Warrant will expire immediately prior to the consummation of such Acquisition.

 

(c)     The Company shall provide Holder with written notice of its request relating to the Cash/Public Acquisition (together with such reasonable information as Holder may reasonably require regarding the treatment of this Warrant in connection with such contemplated Cash/Public Acquisition giving rise to such notice), which is to be delivered to Holder not less than seven (7) Business Days prior to the closing of the proposed Cash/Public Acquisition. In the event the Company does not provide such notice, then if, immediately prior to the Cash/Public Acquisition, the fair market value of one Share (or other security issuable upon the exercise hereof) as determined in accordance with Section 1.3 above would be greater than the Warrant Price in effect on such date, then this Warrant shall automatically be deemed on and as of such date to be exercised pursuant to Section 1.2 above as to all Shares (or such other securities) for which it shall not previously have been exercised, and the Company shall promptly notify Holder of the number of Shares (or such other securities) issued upon such exercise to Holder, and Holder shall be deemed to have restated each of the representations and warranties in Section 4 of the Warrant as the date thereof.

 

(d)     Upon the closing of any Acquisition other than a Cash/Public Acquisition, the acquiring, surviving or successor entity shall assume the obligations of this Warrant, and this Warrant shall thereafter be exercisable for the same securities and/or other property as would have been paid for the Shares issuable upon exercise of the unexercised portion of this Warrant as if such Shares were outstanding on and as of the closing of such Acquisition, subject to further adjustment from time to time in accordance with the provisions of this Warrant.

 

(e)     As used in this Warrant, “Marketable Securities” means securities meeting all of the following requirements: (i) the issuer thereof is then subject to the reporting requirements of Section 13 or Section 15(d) of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), and is then current in its filing of all required reports and other information under the Act and the Exchange Act; (ii) the class and series of shares or other security of the issuer that would be received by Holder in connection with the Acquisition were Holder to exercise this Warrant on or prior to the closing thereof is then traded in Trading Market, and (iii) following the closing of such Acquisition, Holder would not be restricted from publicly re-selling all of the issuer’s shares and/or other securities that would be received by Holder in such Acquisition were Holder to exercise or convert this Warrant in full on or prior to the closing of such Acquisition, except to the extent that any such restriction (x) arises solely under federal or state securities laws, rules or regulations, and (y) does not extend beyond six (6) months from the closing of such Acquisition.

 

SECTION 2.     ADJUSTMENTS TO THE SHARES AND WARRANT PRICE.

 

2.1     Stock Dividends, Splits, Etc. If the Company declares or pays a dividend or distribution on the outstanding shares of the Class payable in common stock or other securities or property (other than cash), then upon exercise of this Warrant, for each Share acquired, unless the conversion ratio of the Class already reflects such event for each Share acquired, Holder shall receive, without additional cost to Holder, the total number and kind of securities and property which Holder would have received had Holder owned the Shares of record as of the date the dividend or distribution occurred. If the Company subdivides the outstanding shares of the Class by reclassification or otherwise into a greater number of shares, the number of Shares purchasable hereunder shall be proportionately increased and the Warrant Price shall be proportionately decreased. If the outstanding shares of the Class are combined or consolidated, by reclassification or otherwise, into a lesser number of shares, the Warrant Price shall be proportionately increased and the number of Shares shall be proportionately decreased. Any adjustment under this Section 2.1 shall become effective at the close of business on the date the subdivision or combination becomes effective.

 

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2.2     Reclassification, Exchange, Combinations or Substitution. Upon any event whereby all of the outstanding shares of the Class are reclassified, exchanged, combined, substituted, or replaced for, into, with or by Company securities of a different class and/or series (other than an Acquisition or a stock dividend, subdivision or combination described in Section 1.6 and Section 2.1 above), then from and after the consummation of such event, this Warrant will be exercisable for the number, class and series of Company securities that Holder would have received had the Shares been outstanding on and as of the consummation of such event, and subject to further adjustment thereafter from time to time in accordance with the provisions of this Warrant. The provisions of this Section 2.2 shall similarly apply to successive reclassifications, exchanges, combinations substitutions, replacements or other similar events. The Company or its successor shall promptly issue to Holder a new warrant for such new securities or other property, which shall provide for adjustments that shall be as nearly equivalent as may be practicable to the adjustments provided for in this Section 2 including, without limitation, appropriate adjustments to the Warrant Price and to the number of securities or property issuable upon exercise of the new warrant.

 

2.3     Conversion of Preferred Stock. If the Class is a class and series of the Company’s convertible preferred stock, in the event that all outstanding shares of the Class are converted, automatically or by action of the holders thereof, into common stock pursuant to the provisions of the Company’s Certificate of Incorporation, then from and after the date on which all outstanding shares of the Class have been so converted, this Warrant shall be exercisable for such number of shares of common stock into which the Shares would have been converted had the Shares been outstanding on the date of such conversion, and the Warrant Price shall equal the Warrant Price in effect as of immediately prior to such conversion divided by the number of shares of common stock into which one Share would have been converted, all subject to further adjustment thereafter from time to time in accordance with the provisions of this Warrant.

 

2.4     Adjustments for Diluting Issuances. Without duplication of any adjustment otherwise provided for in this Section 2, the number of shares of common stock issuable upon conversion of the Shares shall be subject to anti-dilution adjustment from time to time in the manner set forth in the Company’s Certificate of Incorporation as if the Shares were issued and outstanding on and as of the date of any such required adjustment.

 

2.5     No Fractional Share. No fractional Share shall be issuable upon exercise of this Warrant and the number of Shares to be issued shall be rounded down to the nearest whole Share. If a fractional Share interest arises upon any exercise of the Warrant, the Company shall eliminate such fractional Share interest by paying Holder in cash the amount computed by multiplying the fractional interest by (i) the fair market value (as determined in accordance with Section 1.3 above) of a full Share, less (ii) the then-effective Warrant Price.

 

2.6     Notice/Certificate as to Adjustments. Upon each adjustment of the Warrant Price, Class and/or number of Shares, the Company, at the Company’s expense, shall notify Holder in writing within a reasonable time setting forth the adjustments to the Warrant Price, Class and/or number of Shares and facts upon which such adjustment is based. The Company shall, upon written request from Holder, furnish Holder with a certificate of its Chief Financial Officer, including computations of such adjustment and the Warrant Price, Class and number of Shares in effect upon the date of such adjustment.

 

SECTION 3.     REPRESENTATIONS, WARRANTIES AND COVENANTS OF THE COMPANY.

 

3.1     Representations and Warranties. The Company represents and warrants to, and agrees with, Holder as follows:

 

(a)     All Shares which may be issued upon the exercise of this Warrant, and all securities, if any, issuable upon conversion of the Shares, shall, upon issuance, be duly authorized, validly issued, fully paid and non-assessable, and free of any liens and encumbrances except for restrictions provided for herein, under the Voting Agreement (to which Holder hereby agrees to become a party), or under applicable federal and state securities laws. The Company covenants that it shall at all times cause to be reserved and kept available out of its authorized and unissued capital stock such number of shares of the Class, common stock and other securities as will be sufficient to permit the exercise in full of this Warrant and the conversion of the Shares into common stock or such other securities.

 

(b)     The Company’s capitalization table attached hereto as Schedule 1 is true and complete, in all material respects, as of the Issue Date.

 

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3.2     Notice of Certain Events. If the Company at any time:

 

(a)     proposes to declare any dividend or distribution upon the outstanding shares of the Class or common stock, whether in cash, property, stock, or other securities and whether or not a regular cash dividend;

 

(b)     proposes to offer for subscription or sale pro rata to the holders of the outstanding shares of the Class any additional shares of any class or series of the Company’s stock (other than pursuant to contractual pre-emptive rights);

 

(c)     proposes to effect any reclassification, exchange, combination, substitution, reorganization or recapitalization of the outstanding shares of the Class; or

 

(d)     proposes to effect an Acquisition or to liquidate, dissolve or wind up;

 

then, in connection with each such event, the Company shall give Holder:

 

(1)     at least seven (7) Business Days prior written notice of the date on which a record will be taken for such dividend, distribution, or subscription rights (and specifying the date on which the holders of outstanding shares of the Class will be entitled thereto) or for determining rights to vote, if any, in respect of the matters referred to in (a) and (b) above; and

 

(2)     in the case of the matters referred to in (c) and (d) above at least seven (7) Business Days prior written notice of the date when the same will take place (and specifying the date on which the holders of outstanding shares of the Class will be entitled to exchange their shares for the securities or other property deliverable upon the occurrence of such event.

 

Reference is made to Section 1.6(c) whereby this Warrant will be deemed to be exercised pursuant to Section 1.2 hereof if the Company does not give written notice to Holder of a Cash/Public Acquisition as required by the terms hereof. Company will also provide information requested by Holder that is reasonably necessary to enable Holder to comply with Holder’s accounting or reporting requirements.

 

SECTION 4.     REPRESENTATIONS AND WARRANTIES OF HOLDER.

 

Holder represents and warrants to the Company as follows:

 

4.1     Purchase for Own Account. This Warrant and the securities to be acquired upon exercise of this Warrant by Holder are being acquired for investment for Holder’s account, not as a nominee or agent, and not with a view to the public resale or distribution within the meaning of the Act. Holder also represents that it has not been formed for the specific purpose of acquiring this Warrant or the Shares.

 

4.2     Disclosure of Information. Holder is aware of the Company’s business affairs and financial condition and has received or has had full access to all the information it considers necessary or appropriate to make an informed investment decision with respect to the acquisition of this Warrant and its underlying securities. Holder further has had an opportunity to ask questions and receive answers from the Company regarding the terms and conditions of the offering of this Warrant and its underlying securities and to obtain additional information (to the extent the Company possessed such information or could acquire it without unreasonable effort or expense) necessary to verify any information furnished to Holder or to which Holder has access.

 

4.3     Investment Experience. Holder understands that the purchase of this Warrant and its underlying securities involves substantial risk. Holder has experience as an investor in securities of companies in the development stage and acknowledges that Holder can bear the economic risk of such Holder’s investment in this Warrant and its underlying securities and is able, without impairing Holder’s financial condition, to hold this Warrant and its underlying securities for an indefinite period of time and to suffer a complete loss of Holder’s investment. Holder has such knowledge and experience in financial or business matters that Holder is capable of evaluating the merits and risks of its investment in this Warrant and its underlying securities and/or has a preexisting personal or business relationship with the Company and certain of its officers, directors or controlling persons of a nature and duration that enables Holder to be aware of the character, business acumen and financial circumstances of such persons.

 

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4.4     Accredited Investor Status. Holder is an “accredited investor” within the meaning of Regulation D promulgated under the Act.

 

4.5     The Act. Holder understands that this Warrant and the Shares issuable upon exercise hereof have not been registered under the Act in reliance upon a specific exemption therefrom, which exemption depends upon, among other things, the bona fide nature of Holder’s representations as expressed herein. Holder understands that this Warrant and the Shares issued upon any exercise hereof must be held indefinitely unless subsequently registered under the Act and qualified under applicable state securities laws, or unless exemption from such registration and qualification are otherwise available. Holder is aware of the provisions of Rule 144 promulgated under the Act and understands the resale limitations imposed thereby and by the Act.

 

4.6     No Stockholder Rights. This Warrant does not entitle Holder to any voting rights or other rights as a stockholder of the Company prior to the actual, valid exercise hereof. In the absence of valid exercise of this Warrant, no provisions of this Warrant, and no enumeration herein of the rights or privileges of Holder, shall cause Holder to be a stockholder of the Company for any purpose.

 

SECTION 5.     MISCELLANEOUS.

 

5.1     Term; Automatic Cashless Exercise Upon Expiration.

 

(a)     Term. Subject to the provisions of Section 1.6 above, this Warrant is exercisable in whole or in part at any time and from time to time before 6:00 p.m., Pacific Time on the Expiration Date and shall be void thereafter. The Company will cancel this Warrant immediately following the Expiration Date to the extent not exercised pursuant to Section 1 above or Section 5.1(b) below.

 

(b)     Automatic Cashless Exercise upon Expiration. In the event that, upon the Expiration Date, the fair market value of one Share (or other security issuable upon the exercise hereof) as determined in accordance with Section 1.3 above is greater than the Warrant Price in effect on such date, then this Warrant shall automatically be deemed on and as of such date to be exercised pursuant to Section 1.2 above as to all Shares (or such other securities) for which it shall not previously have been exercised, and the Company shall, within a reasonable time, deliver a certificate representing the Shares (or such other securities) issued upon such exercise to Holder.

 

5.2     Legends. Each certificate evidencing Shares (and each certificate evidencing the securities issued upon conversion of any Shares, if any) shall be imprinted with a legend in substantially the following form:

 

THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933 (THE “ACT”) AND MAY NOT BE OFFERED, SOLD OR OTHERWISE TRANSFERRED, ASSIGNED, PLEDGE OR HYPOTHECATED UNLESS AND UNTIL REGISTERED UNDER THE ACT OR UNLESS THE COMPANY HAS RECEIVED AN OPINION OF COUNSEL SATISFACTORY TO THE COMPANY AND ITS COUNSEL THAT SUCH REGISTRATION IS NOT REQUIRED.

 

5.3     Compliance with Securities Laws on Transfer. This Warrant and the Shares issued upon exercise of this Warrant (and the securities issuable, directly or indirectly, upon conversion of the Shares, if any) may not be transferred or assigned in whole or in part except in compliance with applicable federal and state securities laws by the transferor and the transferee (including, without limitation, the delivery of investment representation letters and legal opinions reasonably satisfactory to the Company, as reasonably requested by the Company). The Company shall not require Holder to provide an opinion of counsel if the transfer is an affiliate of Holder, provided that any such transferee is an “accredited investor” as defined in Regulation D promulgated under the Act. Additionally, the Company shall also not require an opinion of counsel if there is no material question as to the availability of Rule 144 promulgated under the Act.

 

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5.4     Registration Rights. The Shares which may be issued upon the exercise of this Warrant (the “Warrant Shares”) shall be considered shares of the Company’s Common Stock to be issued in connection with the Transactions (as defined in the Merger Agreement (as defined herein) for purposes of Section 5.25 of the Merger Agreement. “Merger Agreement” is that certain that certain Agreement and Plan of Merger and Reorganization, by and among the Company, EMBARK MERGER SUB, INC., a Delaware corporation (“Merger Sub”) and Adynxx, Inc. dated as of October 11, 2018.

 

5.5     Business Days. “Business Day” is any day that is not a Saturday, Sunday or a day on which banks in the State of California are closed.

 

5.6     Transfer Procedure. After receipt by Oxford of the executed Warrant, Oxford may transfer all or part of this Warrant to one or more Oxford Affiliate (as defined below), by execution of an Assignment substantially in the form of Appendix 2. Subject to the provisions of Article 5.3 and upon providing the Company with written notice, Oxford, any such Oxford Affiliate and any subsequent Holder, may transfer all or part of this Warrant or the Shares issuable upon exercise of this Warrant (or the Shares issuable directly or indirectly, upon conversion of the Shares, if any) to any other transferee, provided, however, in connection with any such transfer, Oxford, Oxford Affiliate(s) or any subsequent Holder will give the Company notice of the portion of the Warrant being transferred with the name, address and taxpayer identification number of the transferee, and Holder will surrender this Warrant to the Company for reissuance to the transferee(s) (and Holder if applicable). As used in this Section 5.5, an “Oxford Affiliate” means any manager or member of Oxford or any person or entity that, directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with Oxford. Notwithstanding the foregoing, the Holder agrees not to make any disposition of the Warrant or all or any portion of the Shares to any person or entity, including an Oxford Affiliate, (i) unless the transferee qualifies as an “accredited investor” within the meaning of Rule 501(a) of Regulation D promulgated under the Act and (ii) unless and until the transferee has agreed in writing for the benefit of the Company to be bound by the terms of this Warrant and the Voting Agreement.

 

5.7     Notices. All notices and other communications hereunder from the Company to Holder, or vice versa, shall be deemed delivered and effective (i) when given personally, (ii) on the third (3rd) Business Day after being mailed by first-class registered or certified mail, postage prepaid, (iii) upon actual receipt if given by facsimile or electronic mail and such receipt is confirmed by the recipient, or (iv) on the first Business Day following delivery to a reliable overnight courier service, courier fee prepaid, in any case at such address as may have been furnished to the Company or Holder, as the case may be, in writing by the Company or such Holder from time to time in accordance with the provisions of this Section 5.6. All notices to Holder shall be addressed as follows until the Company receives notice of a change of address in connection with a transfer or otherwise:

 

Oxford Finance LLC

133 N. Fairfax Street

Alexandria, VA 22314

Attn: Legal Department

Telephone: (703) 519-4900

Facsimile: (703) 519-5225

Email: LegalDepartment@oxfordfinance.com

 

Notice to the Company shall be addressed as follows until Holder receives notice of a change in address:

 

ALLIQUA BIOMEDICAL, INC.

731 Market Street

Suite 420

San Francisco, California 94103

Attn: Rick Orr, CEO

Email: rorr@adynxx.com

 

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With a copy (which shall not constitute notice) to:

 

Cooley LLP

3175 Hanover Street

Palo Alto, CA 94304

Attention: John McKenna

Email: jmckenna@cooley.com

 

5.8     Waivers and Amendments. Except as expressly provided herein, neither this Warrant nor any term hereof may be amended, waived, discharged or terminated other than by a written instrument referencing this Warrant and signed by the Company and Holder; provided, however, that any term hereof may be changed, waived, discharged or terminated (either generally or in a particular instance and either retroactively or prospectively) by an instrument in writing signed by the party against which enforcement of such change, waiver, discharge or termination is sought. Any waiver, permit, consent or approval of any kind or character on the part of any party of any breach or default under this Warrant, or any waiver on the part of any party of any provisions or conditions of this Warrant, must be in writing and shall be effective only to the extent specifically set forth in such writing.

 

5.9     Attorneys’ Fees. In the event of any dispute between the parties concerning the terms and provisions of this Warrant, the party prevailing in such dispute shall be entitled to collect from the other party all costs incurred in such dispute, including reasonable attorneys’ fees.

 

5.10     Counterparts. This Warrant may be executed in counterparts, all of which together shall constitute one and the same agreement.

 

5.11     Governing Law. This Warrant shall be governed by and construed in accordance with the laws of the State of California, without giving effect to its principles regarding conflicts of law.

 

5.12     Headings. The headings in this Warrant are for purposes of reference only and shall not limit or otherwise affect the meaning of any provision of this Warrant.

 

 

 

[Remainder of page left blank intentionally]

 

[Signature page follows]

 

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IN WITNESS WHEREOF, the parties have caused this Warrant to Purchase Stock to be executed by their duly authorized representatives effective as of the Issue Date written above.

 

	
			“COMPANY”

			
	 	 	 
	
			ALLIQUA BIOMEDICAL, INC., to be renamed ADYNXX, INC.

			
	 	 	 
	 	 	 
	
			By:

				 	 
	 	 	 
	
			Name:

				 	 
	
			 

				(Print)	 
	
			Title:

				 	 
	 	 	 
	 	 	 
	
			“HOLDER”

			
	 	 	 
	 	 	 
	
			OXFORD FINANCE LLC

			
	 	 	 
	 	 	 
	
			By:

				 	 
	 	 	 
	
			Name:

				 	 
	
			 

				(Print)	 
	
			Title:

				 	 

 

 

[Signature Page to Warrant to Purchase Stock]

 

 

 

 

APPENDIX 1

 

NOTICE OF EXERCISE

 

1.       The undersigned Holder hereby exercises its right purchase ___________ shares of the Common Stock of ALLIQUA BIOMEDICAL, INC. (to be renamed ADYNXX, INC.) (the “Company”) in accordance with the attached Warrant To Purchase Stock, and tenders payment of the aggregate Warrant Price for such shares as follows:

 

[   ]     check in the amount of $________ payable to order of the Company enclosed herewith

 

[   ]     Wire transfer of immediately available funds to the Company’s account

 

[   ]     Cashless Exercise pursuant to Section 1.2 of the Warrant

 

[   ]     Other [Describe] __________________________________________

 

2.       Please issue a certificate or certificates representing the Shares in the name specified below:

 

	 	 	 
	 	Holder’s Name	 
	 	 	 
	 	 	 
	 	 	 
	 	(Address)	 

 

3.       By its execution below and for the benefit of the Company, Holder hereby restates each of the representations and warranties in Section 4 of the Warrant to Purchase Stock as of the date hereof.

 

	 	
			HOLDER:

				 
	 	 	 	 
	 	 	 
	 	 	 	 
	 	By:	
			 

				 
	 	 	 	 
	 	Name:	
			 

				 
	 	 	 	 
	 	Title:	
			 

				 
	 	 	 	 
	 	Date:	
			 

				 

 

 

Appendix 1

 

 

 

 

APPENDIX 2

 

ASSIGNMENT

 

For value received, Oxford Finance LLC hereby sells, assigns and transfers unto

 

	Name:	OXFORD TRANSFEREE	 
	 	 	 
	Address:	 	 
	 	 	 
	Tax ID:	 	 

 

that certain Warrant to Purchase Stock issued by ADYNXX, INC. (the “Company”), on November 24, 2015 (the “Warrant”) together with all rights, title and interest therein.

 

	 	 	 	
			OXFORD FINANCE LLC

			
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	By:	
			 

			
	 	 	 	 	 
	 	 	 	Name:	
			 

			
	 	 	 	 	 
	 	 	 	Title:	
			 

			
	 	 	 	 	 
	
			Date:

				 	 	 	 

 

By its execution below, and for the benefit of the Company, [OXFORD TRANSFEREE] makes each of the representations and warranties set forth in Article 4 of the Warrant and agrees to all other provisions of the Warrant as of the date hereof.

 

	 	
			[OXFORD TRANSFEREE]

			
	 	 	 
	 	By:	
			 

			
	 	 	 
	 	Name:	
			 

			
	 	 	 
	 	Title:	
			]

			

 

 

 

 

SCHEDULE 1

 

Company Capitalization Table

 

 

(See attached)

 

 

 

 

 

 

The aggregate number of outstanding shares on May 3, 2019 is 5,808,027.ex_143697.htm

Exhibit 10.4

 

October 15, 2010

 

 

Rick Orr

22 Roselyn Terrace

San Francisco, CA 94118

 

 

Dear Rick:

 

I am pleased to offer you the position of Chief Executive Officer of Adynxx, Inc. (“Adynxx” or the “Company”) effective as of the date of and conditioned upon the initial closing of a Qualified Financing (as defined below) with gross cash proceeds (excluding the conversion of any promissory notes outstanding as of the date hereof) to the Company of at least $4,000,000 (the ‘‘Initial Closing”). As used herein, a “Qualified Financing” shall mean a preferred stock financing of the Company with the principal purpose of raising capital, pursuant to which the Company agrees to issue shares of its Series A Convertible Preferred Stock resulting in gross cash proceeds of at least $12,000,000 in a single transaction; provided, however, that a ‘‘single transaction” shall include a transaction that contemplates multiple or tranched closings. In the event of multiple or tranched closings, the ‘‘Final Closing” shall mean the closing that results in aggregate gross cash proceeds to the Company (including the proceeds from all prior closings) of at least $12,000,000. In the event that the Initial Closing does not occur on or before February 28, 2011 (the “Outside Date”), this employment offer is withdrawn and has no effect. This offer letter agreement (the “Agreement”) sets forth the terms and conditions of your employment with the Company.

 

1.           Position and Salary. In your capacity as Chief Executive Officer you will report to and perform such duties as are required by the Adynxx Board of Directors (the “Board”). Your annual base salary will be $350,000, subject to standard payroll deductions and withholdings.

 

Your target annual bonus will be thirty-five percent (35%) of your annual base salary, subject to standard payroll deductions and withholdings. The amount of your awarded bonus, which may be above or below the target amount based on Company and your individual performance, will be based upon achievement of milestones to be mutually agreed upon between you and the Board. Bonus payments, if any, will be paid as soon as practicable following the determination by the Board that the bonus has been earned, but in no event after the later of (i) March 15 following the calendar year in which such bonuses are earned or (ii) the 15th day of the 3rd month following the close of Adynxx’s fiscal year in which such bonuses are earned.

 

In addition, subject to the Initial Closing you will receive a one-time signing bonus of $87,500 payable concurrent with your first regularly scheduled payroll check following your start date and subject to applicable withholding taxes.

 

 

 

 

Rick Orr

October 15, 2010

Page 2

 

2.           Stock.

 

(a)     As an inducement for you to enter into this Agreement and accept employment with the Company, upon your execution of this Agreement, the Company shall sell to you 3,957,944 shares of its Common Stock (the “Shares”) pursuant to the terms and conditions of the Restricted Stock Purchase Agreement attached hereto as Exhibit A (the ‘‘Purchase Agreement”).

 

(b)     The Board of Directors shall, if required by Section 2(e) of the Purchase Agreement, grant to you an option to purchase a number of shares of Common Stock, if any, as calculated pursuant to and subject to the terms and conditions of such Section 2(e) of the Purchase Agreement.

 

(c)     In the event that the Company sells any additional shares of its Series A Convertible Preferred Stock after the Final Closing of a Qualified Financing (each such event, an ‘‘Additional Closing”), you shall be granted an additional option to purchase stock in a manner consistent with Section 2(e) of the Purchase Agreement such that your total holdings of Company equity securities, including the Shares and all previously granted stock options, represent not less than five percent (5%) of the Common Stock deemed to be outstanding on a fully-diluted and fully-converted basis as of the date of each such Additional Closing. Any such options shall be subject to vesting and repurchase rights consistent with any options that may be granted pursuant to Section 2(e) of the Purchase Agreement, shall expire ten years from the date of grant and shall be exercisable at the fair market value per share of Common Stock of the Company as determined in good faith by the Board of Directors at the time of grant. Any such options will be evidenced by the Company’s then standard form of stock option agreement. Any shares issued upon exercise of such option(s) will be subject to a right of first refusal in favor of the Company and certain restrictions on transfer as may be provided in the agreement memorializing such option.

 

3.            At-Will Employment; Severance.

 

(a)     Your employment with Adynxx will be “at will,” which means that either you or Adynxx may terminate your employment at any time for any reason whatsoever upon thirty (30) days’ written notice. In the event that your employment is terminated by Adynxx without Cause or your employment is terminated due to Constructive Termination, you shall be entitled to receive a severance payment equal to twelve (12) months of your annual base salary effective as of the termination date, twelve (12) months of continued health insurance benefits (assuming you timely elect continued coverage under COBRA), and an amount equal to 100% of the most recent annual bonus paid to you (or, with respect to the bonus for 2011, 100% of the annualized target amount). The cash severance payments shall be made in one lump-sum payment, to be made subject to the limitations set forth in Sections 3(b), 4, and 5.

 

 

 

 

Rick Orr

October 15, 2010

Page 3

 

(b)     The receipt of any severance pay or other benefits pursuant to Section 3 is subject to your signing and not revoking a separation agreement and release of claims in the form attached hereto as Exhibit B (the “Release”) that is effective no later than sixty (60) days following the date of your termination or such earlier period as required by the Release (such deadline, the “Release Deadline”). If the Release does not become effective by the Release Deadline, you will forfeit any rights to severance or other benefits under this Agreement. To become effective, the Release must be executed by you and any revocation periods (as required by statute, regulation, or otherwise) must have expired without you having revoked the Release. In addition, no severance will be paid or provided until the Release actually becomes effective. In the event that your termination occurs at a time during the calendar year where the Release Deadline could occur in the calendar year following the calendar year in which your termination occurs, then any severance under this letter agreement that would be considered Deferred Compensation Separation Benefits (as defined in Section 4) will be paid on the first payroll date to occur during the calendar year following the calendar year in which such termination occurs, or such later time as (i) is required by Section 4, or (ii) the date the Release becomes effective. The first payment shall include all amounts that would have been paid to you had payment commenced on the date your employment terminated.

 

4.         Section 409A. Notwithstanding anything to the contrary in this letter agreement, if you are a “specified employee” within the meaning of Section 409A of the Internal Revenue Code of 1986, as amended (the “Code”), and the final regulations and any guidance promulgated thereunder (“Section 409A”) at the time of your termination, then only that portion of the severance and benefits payable to you pursuant to this letter agreement (other than due to death), if any, and any other severance payments or separation benefits which may be considered deferred compensation under Section 409A (together, the “Deferred Compensation Separation Benefits”), which (when considered together) do not exceed the Section 409A Limit (as defined below) may be made within the first six (6) months following your termination of employment in accordance with the payment schedule applicable to each payment or benefit. Any portion of the Deferred Compensation Separation Benefits in excess of the Section 409A Limit otherwise due to you on or within the six (6) month period following your termination will accrue during such six (6) month period and will become payable in a lump-sum payment on the date six (6) months and one (1) day following the date of your termination of employment. All subsequent Deferred Compensation Separation Benefits, if any, will be payable in accordance with the payment schedule applicable to each payment or benefit.

 

5.         Section 409A Limit. For purposes of this letter agreement, “Section 409A Limit” shall mean the lesser of two (2) times: (i) your annualized compensation based upon the annual rate of pay paid to you during Adynxx’s taxable year preceding the taxable year of your termination of employment as determined under Treasury Regulation 1.409A-1 (b)(9)(iii)(A)(1) and any Internal Revenue Service guidance issued with respect thereto; or (ii) the maximum amount that may be taken into account under a qualified plan pursuant to Section 401(a)(17) of the Code, for the year in which your employment is terminated.

 

 

 

 

Rick Orr

October 15, 2010

Page 4

 

6.           Definitions.

 

(a)     For the purposes hereof, “Change of Control” means the occurrence, in a single transaction or in a series of related transactions, of any one or more of the following events:

 

(i)     (A) there is consummated a merger, consolidation or similar transaction involving (directly or indirectly) Adynxx and, immediately after the consummation of such merger, consolidation or similar transaction, the stockholders of Adynxx immediately prior thereto do not own, directly or indirectly, outstanding voting securities representing more than fifty percent (50%) of the combined outstanding voting power of the surviving entity in such merger, consolidation or similar transaction or more than fifty percent (50%) of the combined outstanding voting power of the parent of the surviving entity in such merger, consolidation or similar transaction, (B) there is consummated any transaction or series of related transactions to which Adynxx is a party in which in excess of fifty percent (50%) of Adynxx’s voting power is transferred, or (C) a majority of the Board ceases to consist of individuals (a) who are members of the Board as of the date of this letter agreement (the “Incumbent Board”) or (b) whose election or nomination for election by Adynxx’s stockholders was approved (i) in connection with the Series A Financing or (ii) by a majority of the Incumbent Board; provided, however, that a Change of Control shall not include (x) any consolidation or merger effected exclusively to change the domicile of Adynxx, or (y) any transaction or series of transactions principally for bona fide equity financing purposes in which cash is received by Adynxx or indebtedness of Adynxx is cancelled or converted or a combination thereof; provided, further, that any individual becoming a director subsequent to the date of this letter agreement whose election or nomination for election by Adynxx’s stockholders was approved by a majority of the directors then comprising the Incumbent Board shall be considered as though such individual were a member of the Incumbent Board;

 

(ii)     there is consummated a sale of assets, lease, license or other disposition of all or substantially all of the consolidated assets of Adynxx, other than a sale, lease, license or other disposition of all or substantially all of the consolidated assets of Adynxx and its subsidiaries to an entity, more than fifty percent (50%) of the combined voting power of the voting securities of which are owned by stockholders of Adynxx in substantially the same proportions as their ownership of Adynxx immediately prior to such sale, lease, license or other disposition; or

 

(iii)     the stockholders of Adynxx approve or the Board approves a plan of complete dissolution or liquidation of Adynxx, or a complete dissolution or liquidation of Adynxx shall otherwise occur.

 

Notwithstanding the foregoing, a public offering (including the initial or any subsequent public offering) of the Common Stock of Adynxx shall not be considered a Change of Control. Once a Change of Control has occurred, no future events will constitute a Change of Control for purposes of this letter agreement.

 

(b)     For purposes hereof, “Cause” shall mean (i) your conviction of a felony involving fraud, dishonesty or moral turpitude; (ii) your willful and persistent refusal to comply with a lawful instruction of the Board so long as the instruction is consistent with the scope and responsibilities of your position; or (iii) your substantial and material failure or refusal to perform according to, or to comply with, the policies, procedures or practices established by Adynxx or the Board or any agreements you may have entered into with Adynxx that results in material harm to the business of Adynxx. The conduct described under subparagraphs (ii) and (iii) will only constitute Cause if such conduct is not cured within fifteen (15) business days of your receipt of written notice from Adynxx or the Board specifying the particulars of the conduct that may constitute Cause. The determination as to whether or not your employment is being terminated for Cause shall be made in good faith by the Board and such reason(s) will be provided to you in the written notice.

 

 

 

 

Rick Orr

October 15, 2010

Page 5

 

(c)     For the purposes hereof, “Constructive Termination” means your voluntary termination of employment after one of the following events occurs without your express written consent: (i) a material reduction in your duties or responsibilities in effect immediately prior to the reduction; (ii) a five percent (5%) or greater reduction by Adynxx in your then current base salary (unless the reduction corresponds to a comparable reduction in salary for substantially all of Adynxx’s other executive employees); (iii) a relocation of your business office to a location more than fifty (50) miles from your business office on the date hereof, except for required travel by you on Adynxx business to an extent substantially consistent with your business travel obligations prior to the date hereof; (iv) a material breach by Adynxx of any provision of this letter agreement or of any other material agreement between you and Adynxx concerning the terms and conditions of your employment, which breach is not cured within twenty (20) days following the date on which Adynxx receives written notice from you of such breach; or (v) any failure by Adynxx to obtain the assumption of this letter agreement by any successor or assign of Adynxx.

 

7.          You will be entitled to twenty five (25) days paid time off each year, accruing pro-rata on a monthly basis, and a minimum of eight (8) holidays. Paid time off includes vacation and sick time. You will be eligible for fringe benefits established by Adynxx and approved by the Board.

 

8.         Adynxx will reimburse you for all reasonable and necessary out-of-pocket expenses incurred by you in connection with services rendered on behalf of Adynxx subject to you providing Adynxx with appropriate substantiation in accordance with Adynxx policy.

 

9.          As an Officer of Adynxx, you will be covered by Directors and Officers Liability insurance. Adynxx agrees to acquire Directors and Officers Liability insurance promptly following the Initial Closing.

 

10.       The waiver by either you or Adynxx of a breach of any provision of this Agreement, amendments, additions or changes thereto, shall not operate or be construed as a waiver of any subsequent breach of the same or of any provision hereof.

 

11.        Any notice required in this Agreement will be valid only when sent by first class mail, certified or registered, postage pre-paid, to the parties at the addresses set out below.

 

12.      As a condition of your employment, you are also required to sign and comply with Adynxx’s standard Proprietary Information and Inventions Assignment Agreement which requires, among other provisions, the assignment of patent rights to any invention made during your employment at Adynxx, and non-disclosure of Adynxx proprietary information.

 

13.      This Agreement, including the Proprietary Information and Inventions Agreement referenced herein, constitutes the entire agreement between you and the Company and it is the complete, final, and exclusive embodiment of your and the Company’s agreement with regard to this subject matter. It is entered into without reliance on any promise or representation other than those expressly contained herein, and all amendments, changes and/or additions to this Agreement must be in writing and signed by both parties.

 

 

 

 

Rick Orr

October 15, 2010

Page 6

 

14.     This Agreement may be executed in separate counterparts, any one of which need not contain signatures of more than one party, but all of which taken together will constitute one and the same Agreement. This Agreement is intended to bind and inure to the benefit of and be enforceable by you and the Company, and your and their respective successors, assigns, heirs, executors and administrators, except that you may not assign any of your duties hereunder and you may not assign any of your rights hereunder without the written consent of the Company, which shall not be withheld unreasonably.

 

15.     The terms of this Agreement and any amendments or additions thereto shall be governed by the laws of the State of California, and you and Adynxx hereby submit to the jurisdiction and venue of the Courts of the State of California for the purpose of any legal actions arising under this Agreement.

 

 

 

 

Rick, this is a very exciting opportunity to help build the company. We are looking forward to your contributions to our success. If this offer meets with your approval, please sign the enclosed copy of this letter where indicated below and return the executed copy to me by the close of business today.

 

	 	Sincerely,	 
	 	 	 	 
	 	Adynxx, Inc.	 
	 	 	 	 
	 	 	 	 
	 	By:	/s/ Stan Abel	 
	 	 	Stan Abel	 
	 	 	Member of the Board of Directors	 
	 	 	 	 
	 	 	Address:	 
	 	 	665 Third Street, Suite 250	 
	 	 	San Francisco, CA 94107	 

 

 

	Agreed and accepted to	 
	this 15th day of October, 2010:	 
	 	 
	 	 
	/s/ Rick Orr	 
	Rick Orr	 
	 	 
	Address:	 
	 	 
	22 Roselyn Terrace	 
	San Francisco, CA 94118	 

 

 

 

 

Exhibit A

RESTRICTED STOCK PURCHASE AGREEMENT

 

 

 

 

 

 

 

 

Exhibit B

FORM OF RELEASE

 

 

 

 

 

 

 

 

RELEASE AGREEMENT

 

I understand that my employment with Adynnx, Inc. (the “Company”) will terminate on [DATE]. I understand that this Release Agreement (the “Release”), together with the offer letter employment agreement between the Company and me, dated [DATE] (the “Employment Agreement”), constitutes the complete, final and exclusive embodiment of the entire agreement between the Company, affiliates of the Company and me with regard to the subject matter hereof. I am not relying on any promise or representation by the Company or an affiliate of the Company that is not expressly stated therein.

 

I hereby confirm my obligations under my proprietary information and inventions agreement with the Company and/or an affiliate of the Company.

 

In consideration of the severance benefits and other consideration provided to me under the Employment Agreement that I am not otherwise entitled to receive, I hereby generally and completely release the Company and its affiliates, and their parents, subsidiaries, successors, predecessors and affiliates, and their current and former partners, members, directors, officers, employees, stockholders, shareholders, agents, attorneys, predecessors, successors, insurers, affiliates and assigns, from any and all claims, liabilities and obligations, both known and unknown, that arise out of or are in any way related to events, acts, conduct, or omissions occurring at any time prior to and including the date I sign this Release (collectively, the “Released Claims”). The Released Claims include, but are not limited to: (a) all claims arising out of or in any way related to my employment with the Company and its affiliates, or their affiliates, or the termination of that employment; (b) all claims related to my compensation or benefits, including salary, bonuses, commissions, vacation pay, expense reimbursements, severance pay, fringe benefits, stock, stock options, or any other ownership, equity, or profits interests in the Company and its affiliates, or their affiliates; (c) all claims for breach of contract, wrongful termination, and breach of the implied covenant of good faith and fair dealing; (d) all tort claims, including claims for fraud, defamation, emotional distress, and discharge in violation of public policy; and (e) all federal, state, and local statutory claims, including claims for discrimination, harassment, retaliation, attorneys’ fees, or other claims arising under the federal Civil Rights Act of 1964 (as amended), the federal Americans with Disabilities Act of 1990 (as amended), the federal Age Discrimination in Employment Act (as amended) (“ADEA”), the federal Employee Retirement Income Security Act of 1974 (as amended), and the California Fair Employment and Housing Act (as amended).

 

Notwithstanding the foregoing, I understand that the following rights or claims are not included in the Released Claims: (a) any rights I have under this Release; (b) any rights that cannot be waived under applicable state or federal law; (c) any rights I have to file or pursue a claim for workers’ compensation or unemployment insurance; or (d) any rights that I have to indemnification (including any right to reimbursement of expenses) arising under applicable law, the certificate of incorporation or by-laws (or similar constituent documents of the Company), any indemnification agreement between the Company and me, or any directors’ and officers’ liability insurance policy of the Company. In addition, I understand that nothing in this Release prevents me from filing, cooperating with, or participating in any proceeding before the Equal Employment Opportunity Commission, the Department of Labor, the California Department of Fair Employment and Housing, or any other government agency, except that I hereby waive my right to any monetary benefits in connection with any such claim, charge or proceeding. I hereby represent and warrant that, other than the claims identified in this paragraph, I am not aware of any claims I have or might have that are not included in the Released Claims.

 

 

 

 

I acknowledge that I am knowingly and voluntarily waiving and releasing any rights I may have under the ADEA, and that the consideration given under the Plan for the waiver and release in this paragraph is in addition to anything of value to which I was already entitled. I further acknowledge that I have been advised by this writing, as required by the ADEA, that: (a) my waiver and release do not apply to any rights or claims that may arise after the date I sign this Release; (b) I should consult with an attorney prior to signing this Release (although I may choose voluntarily not do so); (c) I have twenty-one (21) days to consider this Release (although I may choose voluntarily to sign this Release earlier); (d) I have seven (7) days following the date I sign this Release to revoke the Release by providing written notice to an officer of the Company; and (e) this Release shall not be effective until the date upon which the revocation period has expired, which shall be the eighth day after I sign this Release provided I have not revoked it.

 

I acknowledge that I have read and understand Section 1542 of the California Civil Code which reads as follows: “A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor.” I hereby expressly waive and relinquish all rights and benefits under that section and any law of any jurisdiction of similar effect with respect to my release of any claims hereunder.

 

I hereby represent that I have been paid all compensation owed and for all hours worked; I have received all the leave and leave benefits and protections for which I am eligible pursuant to the Family and Medical Leave Act, the California Family Rights Act, or otherwise; and I have not suffered any on-the-job injury for which I have not already filed a workers’ compensation claim.

 

I acknowledge that to become effective, I must sign and return this Release to the Company so that it is received not later than twenty-one (21) days following the date it is provided to me or such other date as specified by the Company.

 

	 	Employee	 
	 	 	 
	 	 	 
	 	Printed Name:	 
	 	 	 
	 	Signature:	 
	 	 	 
	 	Date:

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