EXHIBIT 4.13
DELIVERY OPTIONS FOR SUBSCRIPTION RIGHTS CERTIFICATE
Delivery other than in the manner or to the address listed below will not constitute valid delivery.
If delivering by mail, hand or overnight courier:
American Stock Transfer & Trust Company, LLC
Operations Center
Attn: Reorganization Department
6201 15th Avenue
Brooklyn, New York 11219
PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY.
FORM 1-EXERCISE OF SUBSCRIPTION RIGHTS
| PLEASE PRINT ALL INFORMATION CLEARLY AND LEGIBLY | FORM 3-DELIVERY TO DIFFERENT ADDRESS | ||||
SECTION 1: OFFERING INSTRUCTIONS (check the appropriate boxes) IF YOU WISH TO SUBSCRIBE FOR YOUR FULL ENTITLEMENT OF SUBSCRIPTION RIGHTS: o I apply for ALL of my entitlement of new shares pursuant to the basic subscription | If you wish for the Common Stock underlying your subscription rights to be delivered to an address different from that shown on the face of this Subscription Rights Certificate, please enter the alternate address below, sign under Form 4 and have your signature guaranteed under Form 5. | ||||
___________________________ x [_______ ] =__________________x $ [_______]= no. of subscription rights) (no. of new shares) (per share) | ______________________________________________________________ ______________________________________________________________ _____________________________________________________________ | ||||
$____________________________ Example: If you own 1,000 shares of common stock, your basic subscription right permits the purchase of [_______] shares. (1,000 purchase rights/[____] = [___], with fractional shares rounded down to the nearest whole number). o In addition, I apply for additional shares pursuant to the oversubscription privilege* ________________ x $[____] = $_______________ (no. of new shares) (per share) IF YOU DO NOT WISH TO APPLY FOR YOUR FULL ENTITLEMENT OF SUBSCRIPTION RIGHTS: o I apply for ________________ x $[____] = $_______________ (no. of new shares) (per share) Amount of check enclosed or wire transmitted (for brokers, dealers and other nominees only): $_______________________ IF YOU DO NOT WISH TO EXERCISE YOUR RIGHT TO SUBSCRIBE: Please disregard this mailing. | FORM 4-SIGNATURE TO SUBSCRIBE: I acknowledge that I have received the Prospectus for this Rights Offering and I hereby irrevocably subscribe for the number of shares indicated above on the terms and conditions specified in the Prospectus. Signature(s): ____________________________________________________ IMPORTANT: The signature(s) must correspond with the name(s) as printed on the reverse of this Subscription Rights Certificate in every particular, without alteration or enlargement, or any other change whatsoever. FORM 5-SIGNATURE GUARANTEE This form must be completed if you have completed any portion of Form 3. Signature Guaranteed: _____________________________________________ (Name of Bank or Firm) By:_____________________________________________________________ (Signature of Officer) IMPORTANT: The signature(s) should be guaranteed by an eligible guarantor institution (bank, stock broker, savings & loan association or credit union) with membership in an approved signature guarantee medallion program pursuant to Securities and Exchange Commission Rule 17Ad-15. | ||||
* You can only participate in the oversubscription privilege if you have subscribed
for your full entitlement of new shares pursuant to the basic subscription.
METHOD OF PAYMENT (CHECK ONE)
| ¨ | Check or bank draft payable to “American Stock Transfer & Trust Company, LLC as Subscription Agent.” |
| ¨ | For brokers, dealers, and other nominees only: Wire transfer of immediately available funds directly to the account maintained by American Stock Transfer & Trust Company, LLC, as Subscription Agent, for purposes of accepting subscriptions in this Rights Offering at _______________________________, with reference to the rights holder's name. |
FORM 2-ADDRESS OF PRINCIPAL PLACE OF RESIDENCE
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