Exhibit 99.5
FORM OF BENEFICIAL OWNER ELECTION FORM
SENESTECH, INC.
The undersigned acknowledge(s) receipt of your letter and the enclosed materials referred to therein relating to the rights offering (the “Rights Offering”) by SenesTech, Inc., a Delaware corporation (the “Company”), of non-transferable subscription rights (the “Subscription Rights”) to purchase Units. Each Unit entitles the holder to one share of common stock of the Company, $0.001 par value (the “Common Stock”) and one Warrant. Each Warrant will be exercisable for one share of CommonStock.This will instruct you whether to exercise Subscription Rights to purchase Units held by you for the account of the undersigned, pursuant to the terms and subject to the conditions set forth in the Prospectus. (Check the applicable boxes and provide all required information.)
| ☐ | Please DO NOT EXERCISE SUBSCRIPTION RIGHTS for Units. | |||||
| ☐ | Please EXERCISE SUBSCRIPTION RIGHTS for Units as set forth below: | |||||
| No. of Units | Per Units Subscription Price | Payment | ||||
| Basic Subscription Right | [________] | X | $[______] | = | $[____________] | |
| Over Subscription Right | [________] | X | $[______] | = | $[____________] | |
| Total Payment Required | $[____________] | |||||
| If you spoke with a broker who solicited such exercise, please indicate the name of the person or entity you spoke with: | ||||||
| ______________________________________________ | ||||||
| ☐ | Payment in the following amount is enclosed $_________ (must match Total Payment Required above) | |||||
| ☐ | Please deduct payment from the following account as follows: | |||||
| Type of Account: | ______________________ | |||||
| Account Number: | ______________________ | |||||
| Amount to be deducted: | $______________________ | |||||
I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:
| ● | Irrevocably elect to purchase the number of Units indicated above upon the terms and conditions specified in the Prospectus; and |
| ● | Agree that if I (we) fail to pay for the Units I (we) have elected to purchase, the exercise will be invalid. |
| Signature: | ||
| Name: | ||
| Title | ||
| Address: | ||
| Telephone: | ||
| Date: |
