Exhibit 10.3
FORM OF WARRANT
THE SECURITIES REPRESENTED BY THIS CERTIFICATE HAVE NOT BEEN REGISTERED UNDER
THE SECURITIES ACT OF 1933, AS AMENDED (THE "SECURITIES ACT"), OR UNDER THE
SECURITIES LAWS OF CERTAIN STATES. THESE SECURITIES ARE SUBJECT TO RESTRICTIONS
ON TRANSFERABILITY AND RESALE AND MAY NOT BE TRANSFERRED OR RESOLD EXCEPT AS
PERMITTED UNDER THE ACT AND THE APPLICABLE STATE SECURITIES LAWS, PURSUANT TO
REGISTRATION OR EXEMPTION THEREFROM AND WITH THE CONSENT OF THE ISSUER.
INVESTORS SHOULD BE AWARE THAT THEY MAY BE REQUIRED TO BEAR THE FINANCIAL RISKS
OF THIS INVESTMENT FOR AN INDEFINITE PERIOD OF TIME. THE ISSUER OF THESE
SECURITIES MAY REQUIRE AN OPINION OF COUNSEL IN FORM AND SUBSTANCE SATISFACTORY
TO THE ISSUER TO THE EFFECT THAT ANY PROPOSED TRANSFER OR RESALE IS IN
COMPLIANCE WITH THE SECURITIES ACT AND ANY APPLICABLE STATE SECURITIES LAWS.
Warrant No. A-1 Date of Issuance: December __, 1996
ABLE TELCOM HOLDING CORP.
Common Stock Purchase Warrant
Able Telcom Holding Corp. (the "Company"), for value received, hereby
certifies that ________________________, or its registered assigns (the
"Registered Holder"), is entitled, subject to the terms set forth below, to
purchase from the Company, at any time and from time to time on or after the
first anniversary of the date hereof (except as provided in Section 8 hereof)
and on or before the Expiration Date (as defined in Section 6 below) (the
"Exercise Period") ______ shares of Common Stock of the Company, par value $.001
per share (the "Common Stock"), at a purchase price per share equal to $9.82.
The shares purchasable upon exercise of this Warrant, and the purchase price per
share shall be adjusted from time to time pursuant to the provisions of this
Warrant and are hereinafter referred to as the "Warrant Stock" and the "Purchase
Price," respectively.
This Warrant is issued pursuant to, and is subject to the terms and
conditions of the Series A Preferred Stock Purchase Agreement dated December 20,
1996, by and among the Company and certain Investors (the "Purchase Agreement").
1. Number of Shares. Subject to the terms and conditions hereinafter set
forth, the Registered Holder is entitled, upon surrender of this Warrant, to
purchase from the Company up to ________ shares of Common Stock, subject to
adjustment as set forth herein.
2. Exercise.
(a) Manner of Exercise. This Warrant may be exercised by the Registered
Holder, in whole or in part, by surrendering this Warrant at any time during the
Exercise Period, with the purchase form appended hereto as Exhibit A duly
executed by such Registered Holder or by such Registered Holder's duly
authorized attorney, at the principal office of the Company, or at such other
office or agency as the Company may designate in writing, accompanied by payment
in full of the Purchase Price payable in respect of the number of shares of
Warrant Stock purchased upon such exercise, and applicable documentary stamp or
other taxes. The total purchase price may be paid by cash, check, wire transfer,
or if requested by Registered Holder in the purchase form, in the manner set
forth in the following paragraph. Notwithstanding the foregoing, the Registered
Holder may only exercise this Warrant for such number of shares of Common Stock
that would result in such Registered Holder being the beneficial owner of up to,
but no more than 4.99% of the Company's then outstanding Common Stock; provided,
however, that the limitation described in this subsection 2(a) shall not prevent
a Registered Holder from exercising this Warrant at any other time thereafter
that does not result in the Registered Holder exceeding such limit.
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In addition to the method of payment set forth above and in lieu of any
cash payment required, the Registered Holder shall have the right, at any time
that there does not exist an effective registration statement filed pursuant to
the Securities Act covering the Warrant Stock, to exercise this Warrant in full
or in part by surrendering this Warrant in the manner specified above in
exchange for the number of shares of Warrant Stock equal to the product of (x)
the number of shares as to which this Warrant is being exercised multiplied by
(y) a fraction, the numerator of which is the Market Price (as defined below)
less the Purchase Price, and the denominator of which is the Market Price. For
purpose of this paragraph, the term "Market Price" shall mean the average
closing bid price quoted on a share of Common Stock on the Nasdaq National
Market for the three (3) trading days immediately prior to the date of the
delivery to the Company of a purchase form (or if the Company's Common Stock is
not traded or listed on the Nasdaq National Market or any other principal
securities market, the average of the closing bid prices in the over-the-counter
market on such days as reported by Nasdaq or any comparable system, or if not so
reported, as reported by any New York Stock Exchange member firm selected by the
Company for such purpose.
(b) Effective Time of Exercise. Each exercise of this Warrant shall
be deemed to have been effected immediately prior to the close of business on
the day on which this Warrant shall have been surrendered to the Company as
provided in Section 2(a) above. At such time, the person or persons in whose
name or names any certificates for Warrant Stock shall be issuable upon such
exercise as provided in Section 2(c) below shall be deemed to have become the
holder or holders of record of the Warrant Stock represented by such
certificates.
(c) Delivery to Registered Holder. As soon as practicable after the
exercise of this Warrant in whole or in part, and in any event within three (3)
trading days thereafter, the Company, at its expense, will cause to be issued in
the name of, and delivered to, the Registered Holder, or as such Registered
Holder (upon payment by such Registered Holder of any applicable transfer taxes)
may direct:
(i)a certificate or certificates for the number of shares of Warrant Stock
to which such Registered Holder shall be entitled, and
(ii) in case such exercise is in part only, a new warrant or warrants
(dated the date hereof) of like tenor, calling in the aggregate on the face or
faces thereof for the number of shares of Warrant Stock equal (without giving
effect to any adjustment therein) to the number of such shares called for on the
face of this Warrant minus the number of such shares purchased by the Registered
Holder upon such exercise as provided in Section 2(a) above.
3. Adjustments.
(a) If outstanding shares of the Common Stock shall be subdivided
into a greater number of shares, or if a dividend in Common Stock shall be paid
in respect of Common Stock, the Purchase Price in effect immediately prior to
such subdivision or at the record date of such dividend shall simultaneously
with the effectiveness of such subdivision or immediately after the record date
of such dividend be proportionately reduced. If outstanding shares of Common
Stock shall be combined into a smaller number of shares, the Purchase Price in
effect immediately prior to such combination shall, simultaneously with the
effectiveness of such combination, be proportionately increased. When any
adjustment is required to be made in the Purchase Price, the number of shares of
Warrant Stock purchasable upon the exercise of this Warrant shall automatically
be changed to equal the number determined by dividing (i) an amount equal to the
number of shares issuable upon the exercise of this Warrant immediately prior to
such adjustment, multiplied by the Purchase Price in effect immediately prior to
such adjustment, by (ii) the Purchase Price in effect immediately after such
adjustment.
(b) In the case of any reclassification or change in the number of
outstanding securities of the Company or in the case of any reorganization of
the Company (or any other corporation the stock or securities of which are at
the time receivable upon the exercise of this Warrant) or any similar corporate
reorganization on or after the date hereof, then and in each such case the
holder of this Warrant, upon the exercise hereof at any time after the
consummation of such reclassification, change, reorganization, merger or
conveyance, shall be entitled to receive, in lieu of the
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stock or other securities and property receivable upon the exercise hereof prior
to such consummation, the stock or other securities or property to which such
holder would have been entitled upon such consummation if such holder had
exercised this Warrant immediately prior thereto, all subject to further
adjustment as provided in subsection 3(a); and in each such case, the terms of
this Section 3 shall be applicable to the shares of stock or other securities
properly receivable upon the exercise of this Warrant after such consummation.
(c) Issuance of Common Stock Below Purchase Price. In case the
Company shall issue or sell shares of Common Stock or rights, options, warrants
or convertible or exchangeable securities containing the right to subscribe for
or purchase shares of Common Stock (other than upon conversion of Series A
Preferred Stock, exercise of a Warrant, pursuant to an employee benefit plan or
in consideration for the acquisition of the majority of the common stock or all
or substantially all of the assets of another business entity), in any
transaction which is not subject to the right of first refusal contained in
Section 5 of that certain Series A Preferred Stock Purchase Agreement, dated
December 20, 1996, among the Company, Credit Suisse First Boston Corporation and
Silverton International Fund Limited at a price per share of Common Stock
(determined, in the case of rights, options, warrants or convertible or
exchangeable securities, by dividing (A) the total amount receivable by the
Company in consideration of the issuance and sale of such rights, options,
warrants or convertible or exchangeable securities, plus the total consideration
payable to the Company upon exercise, conversion or exchange thereof, by (B) the
total number of shares of Common Stock covered by such rights, options, warrants
or convertible or exchangeable securities) that is lower (at the date of such
sale or issuance) than the Purchase Price, or for no consideration, then in each
case the number of shares of Common Stock thereafter issuable upon the exercise
of all Warrants then outstanding shall be increased in a manner determined by
multiplying the number of shares of Common Stock theretofore issuable upon the
exercise of all Warrants then outstanding by a fraction, of which the numerator
shall be the number of shares of Common Stock outstanding immediately prior to
the sale or issuance plus the number of additional shares of Common Stock
offered for subscription or purchase or to be issued upon conversion or exchange
of such convertible or exchangeable securities, and of which the denominator
shall be the number of shares of Common Stock outstanding immediately prior to
the sale or issuance plus the number of shares of Common Stock which the
"aggregate consideration to be received by the Company" (as defined in the
following paragraph) in connection with such sale or issuance would purchase at
the Purchase Price.
For the purpose of such adjustments the "aggregate consideration to be
received by the Company" therefor shall be deemed to be the consideration
received by the Company for such Common Stock, rights options, warrants or
convertible or exchangeable securities plus any consideration or premiums stated
in such rights, options, warrants or convertible or exchangeable securities to
be paid for the shares of Common Stock covered thereby.
In case the Company shall issue or sell shares of Common Stock or rights,
options, warrants or convertible or exchangeable securities containing the right
to subscribe for or purchase shares of Common Stock for a consideration
consisting, in whole or in part, of property other than cash or its equivalent,
then in determining the "price per share of Common Stock" and the
"consideration" receivable by or payable to the Company for purposes of this
Section 3(c), the Board of Directors of the Company shall determine, in good
faith, the fair value of such property. In case the Company shall issue and sell
rights, options, warrants or convertible or exchangeable securities containing
the right to subscribe for or purchase shares of Common Stock, together with one
or more other securities as part of a unit at a price per unit, then in
determining the "price per share of Common Stock" and the "consideration"
receivable by or payable to the Company for purposes of this Section 3(c), the
Board of Directors of the Company shall determine, in good faith, the fair value
of the rights, options, warrants or convertible or exchangeable securities then
being sold as part of such unit.
Any increase of the number of shares of Common Stock issuable upon
exercise of all Warrants then outstanding made pursuant to this Section 3(c)
shall be allocated among such Warrants on a pro rata basis.
(d) Expiration of Rights, Options and Conversion Privileges. Upon
the expiration of any rights, options, warrants or conversion or exchange rights
that have previously resulted in an adjustment under this Section 3(c), if any
thereof shall not have been exercised, the number of shares of Common Stock
issuable upon the exercise of each Warrant shall be readjusted and shall
thereafter, upon any future exercise, be such as they would have been had
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they been originally adjusted (or had the original adjustment not been required,
as the case may be) as if (i) the only shares of Common Stock so issued were the
shares of Common Stock, if any, actually issued or sold upon the exercise of
such rights, options, warrants or conversion or exchange rights and (ii) such
shares of Common Stock, if any, were issued or sold for the consideration
actually received by the Company upon such exercise plus the consideration, if
any, actually received by the Company for issuance, sale or grant of all such
rights, options, warrants or conversion or exchange rights whether or not
exercised; provided that no such readjustment shall have the effect of
decreasing the number of shares issuable upon exercise of each Warrant by a
number that is in excess of the amount or number of the adjustment initially
made in respect of the issuance, sale or grant of such rights, options, warrants
or conversion or exchange rights or shall have the effect of decreasing the
number of shares of Common Stock that have been issued upon exercise of any
Warrants prior to the date of such readjustment.
(e) Adjustment of Exercise Price. Whenever the number of shares of
Common Stock purchasable upon the exercise of each Warrant is adjusted, as
provided in Section 3(c), the Purchase Price of each share of Common Stock
payable upon exercise of such Warrant shall be adjusted by multiplying such
Purchase Price immediately prior to such adjustment by a fraction, the numerator
of which shall be the number of shares issuable upon the exercise of each
Warrant immediately prior to such adjustment, and the denominator of which shall
be the number of shares so issuable immediately thereafter.
(f) When any adjustment is required to be made in the Purchase
Price, the Company shall promptly mail to the Registered Holder a certificate
setting forth the Purchase Price after such adjustment and setting forth a brief
statement of the facts requiring such adjustment. Such certificate shall also
set forth the kind and amount of stock or other securities or property into
which this Warrant shall be exercisable following the occurrence of any of the
events specified in subsections 3(a) or (b) above.
(g) Subject to the provisions of Section 8 hereof, in the event
that, prior to the first anniversary of the date hereof, the Registered Holder
has converted any shares of Series A Preferred Stock issued to such Registered
Holder on the date hereof into Common Stock, the number of shares of Common
Stock issuable upon the exercise of this Warrant shall be reduced by an amount
equal to 200 shares of Common Stock (as adjusted as provided herein) for each
share of Series A Preferred Stock which has been converted into Common Stock.
4. Transfers.
(a) This Warrant and all rights hereunder are being issued in
connection with the issuance of the Series A Preferred Stock and are
transferable, in whole or in part, only with the prior written consent of the
Company, which consent will not be unreasonably withheld, and in compliance with
subsections 4(b) through 4(d) hereof, upon surrender of this Warrant with a
properly executed assignment (in the form of Exhibit B hereto) at the principal
office of the Company.
(b) Each holder of this Warrant acknowledges that this Warrant and
the Warrant Stock have not been registered under the Securities Act, and agrees
not to sell, pledge, distribute, offer for sale, transfer or otherwise dispose
of this Warrant or any Warrant Stock issued upon its exercise in the absence of
(i) an effective registration statement under the Securities Act as to this
Warrant or the Warrant Stock and registration or qualification of this Warrant
or the Warrant Stock under any applicable blue sky or state securities law then
in effect, or (ii) an opinion of counsel, reasonably satisfactory to the
Company, that such registration and qualification are not required. Each
certificate or other instrument for Warrant Stock issued upon the exercise of
this Warrant shall bear a legend substantially to the foregoing effect.
Notwithstanding the foregoing, no such registration statement or opinion of
counsel (unless required by the transfer agent of the Company with respect to
the Warrant Stock) shall be required (A) for any transfer of any Warrant or
Warrant Stock in compliance with Rule 144 or Rule 144A of the Securities Act;
(B) for any transfer of Warrants or Warrant Stock by a Registered Holder that is
a partnership or a corporation to (x) a partner of such partnership or an
"affiliate" (as such term is defined in Regulation D under the Securities Act)
of such corporation (in which case no consent of the Company pursuant to Section
4(a) above shall be required), (y) a retired partner of such partnership who
retires after the date hereof or (z) the estate of any such partner or
shareholder; or (C) for the transfer by gift, will or intestate succession by
any Registered Holder to his or her spouse or lineal descendants
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or successors or any trust for any of the foregoing. Each holder of this
Warrant, by acceptance hereof, acknowledges that the Warrant and the Warrant
Stock are being (and will be) acquired solely for such holder's own account and
not as nominee for any other party, and for investment; provided, however, that
in making such representation, the holder shall not be required to hold the
Warrant or any Warrant Stock for any minimum or other specific term, except as
required by Federal and applicable state securities laws.
(c) A Registered Holder shall deliver written notice of any transfer
of this Warrant permitted hereunder, in the form of Exhibit B hereto, to the
Company within three (3) business days after such transfer. Such notice shall
include the name and address of the transferee of this Warrant. The Company will
maintain a register containing the names and addresses of the Registered Holders
of this Warrant, and the Company shall enter thereon the name and address of any
transferee of this Warrant within three (3) business days after its receipt of
written notice thereof from the Registered Holder. Any Registered Holder may
change such Registered Holder's address as shown on the warrant register by
written notice to the Company requesting such change.
(d) Until any transfer of this Warrant is made in the warrant
register, the Company may treat the Registered Holder of this Warrant as the
absolute owner hereof for all purposes; provided, however, that if and when this
Warrant is properly assigned in blank, the Company may (but shall not be
required to) treat the bearer hereof as the absolute owner hereof for all
purposes, notwithstanding any notice to the contrary.
5. No Impairment. The Company will not, by amendment of its charter or
through reorganization, consolidation, merger, dissolution, sale of assets or
any other voluntary action, avoid or seek to avoid the observance or performance
of any of the terms of this Warrant, but will (subject to Section 15 below) at
all times in good faith assist in the carrying out of all such terms and in the
taking of all such action as may be necessary or appropriate in order to protect
the rights of the holder of this Warrant against impairment.
6. Termination. This Warrant (and the right to purchase securities upon
exercise hereof) shall terminate three (3) years after the date hereof (the
"Expiration Date").
7. Notices of Certain Transactions. In case:
(a) the Company shall take a record of the holders of its Common
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,
then, and in each such case, the Company will mail or cause to be mailed to the
Registered Holder of this Warrant 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 or
winding-up is to take place, and the time, if any is to be fixed, as of which
the holders of record of Common Stock (or such other stock or securities at the
time deliverable upon such reorganization, reclassification, consolidation,
merger, transfer, dissolution, liquidation or winding-up) 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.
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8. Optional Redemption. If, at any time, the Company delivers a written
redemption notice to the Registered Holder under subsection 8(b)(i) of Article
III of the Articles of Incorporation of the Company, as amended, with regard to
the shares of Series A Preferred Stock owned by Registered Holder, the Company,
concurrently with such written redemption notice, shall deliver a separate
written notice to the Registered Holder stating that the Registered Holder has
ninety (90) days from the date such separate written notice is delivered to the
Registered Holder to exercise the Warrant for the Purchase Price or the Company
will redeem the Warrant with respect to any shares of Warrant Stock not so
converted at a purchase price of $.01 per underlying share of Warrant Stock on
the date that is thirty (30) days after the date of such separate written
notice. At the end of such ninety (90) day period, the Company may redeem the
Warrant with respect to any portion thereof that has not been converted into
shares of Warrant Stock by delivering to the Registered Holder the purchase
price stated in this Section 8 with respect to such unconverted portion of the
Warrant via check or wire transfer. The ninety (90) day period set forth in this
Section 8 shall be extended by the number of days during which a registration
statement is not effective or otherwise not available for use by the Registered
Holders.
9. Reservation of Stock. The Company will at all times reserve and keep
available, solely for the issuance and delivery upon the exercise of this
Warrant, such shares of Warrant Stock and other stock, securities and property,
as from time to time shall be issuable upon the exercise of this Warrant.
10. Exchange of Warrants. Upon the surrender by the Registered Holder of
any Warrant or Warrants, properly endorsed, to the Company at the principal
office of the Company, the Company will, subject to the provisions of Section 4
hereof, issue and deliver to or upon the order of such Registered Holder, at the
Company's expense, a new Warrant or Warrants of like tenor, in the name of such
Registered Holder or as such Registered Holder (upon payment by such Registered
Holder of any applicable transfer taxes) may direct, calling in the aggregate on
the face or faces thereof for the number of shares of Common Stock called for on
the face or faces of the Warrant or Warrants so surrendered.
11. Replacement of Warrants. Upon receipt of evidence reasonably
satisfactory to the Company of the loss, theft, destruction or mutilation of
this Warrant and (in the case of loss, theft or destruction) upon delivery of an
indemnity agreement in an amount reasonably satisfactory to the Company, or (in
the case of mutilation) upon surrender and cancellation of this Warrant, the
Company will issue, in lieu thereof, a new Warrant of like tenor.
12. Notices. Unless otherwise provided, any notice required or permitted
under this Warrant shall be given in writing and addressed to the party to be
notified at the address or facsimile number indicated for such party set forth
in the records of the Company for such purpose or, in the case of the Company,
at 1601 Forum Place, Suite 1110, West Palm Beach, Florida 33401, attention
Daniel Osborne, Chief Accounting Officer, or at such other address as any
Registered Holder or the Company may designate by giving ten (10) days advance
written notice to all other parties. Such notice shall be deemed effectively
given upon (i) personal delivery to the party to be notified or (ii) delivery by
overnight courier to the party to be notified or (iii) on the fifth (5th)
business day following deposit with the United States Post Office, by registered
or certified mail, postage prepaid or (iv) delivery via facsimile and
confirmation generated by the sender's facsimile machine.
13. No Rights as Shareholder. Until the exercise of this Warrant, the
Registered Holder of this Warrant shall not have or exercise any rights by
virtue hereof as a shareholder of the Company solely by reason of being a holder
of this Warrant.
14. No Fractional Shares. No fractional shares of Common Stock will be
issued in connection with any exercise hereunder. In lieu of any fractional
shares which would otherwise be issuable, the Company shall pay cash equal to
the product of such fraction multiplied by the fair market value of one share of
Common Stock on the date of exercise, as determined by the average closing bid
price, as reported on the Nasdaq National Market (or such other principal
securities market on which the shares of Common Stock are traded) of one such
share for the three (3) trading days immediately preceding the date of exercise.
15. Amendment or Waiver. Any term of this Warrant may be amended or waived
upon written consent of the Company and all of the holders hereof.
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16. 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.
17. Governing Law. This Warrant shall be governed, construed and
interpreted in accordance with the laws of the State of New York, without giving
effect to principles of conflicts of law.
ABLE TELCOM HOLDING CORP.
By:/s/William J. Mercurio
----------------------------------------
Name: William J. Mercurio
Title:President and Chief Executive Officer
Address: 1601 Forum Place, Suite 1110
West Palm Beach, Florida 33401
Facsimile Number: (561) 688-0455
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EXHIBIT A
PURCHASE FORM
To: Able Telcom Holding Corp.
Dated:________________________
The undersigned, pursuant to the provisions set forth in the attached
Warrant, hereby irrevocably elects to purchase _______ shares of the Common
Stock covered by such Warrant and herewith makes payment of $_________,
representing the full purchase price for such shares at the price per share
provided for in such Warrant. The undersigned [does] [does not] choose to pay
the purchase price pursuant to a cashless exercise of the Warrants. The
undersigned certifies to the Company that its election to purchase does not
cause the undersigned to be the beneficial owner of more than 4.99% of the
Common Stock of the Company as of the date hereof.
The undersigned further acknowledges that it has reviewed the
representations and warranties contained in Section 4 of the Purchase Agreement
(as defined in the Warrant) and by its signature below hereby makes such
representations and warranties to the Company. Defined terms contained in such
representations and warranties shall have the meanings assigned to them in the
Purchase Agreement, provided that the term "Investor" shall refer to the
undersigned and the term "Purchased Shares" shall refer to the Warrant Stock.
HOLDER:
------------------------------------
By:_________________________________
Title:____________________________________
Address:____________________________
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EXHIBIT B
ASSIGNMENT FORM
FOR VALUE RECEIVED,_________________________________________ hereby sells,
assigns and transfers all of the rights of the undersigned under the attached
Warrant with respect to the number of shares of Common Stock covered thereby set
forth below,unto:
Name of Assignee Address/Facsimile Number No. of Shares
The undersigned hereby certifies to the Company that (i) the undersigned
is the Registered Holder of the attached Warrant and (ii) Assignee is a person
or entity identified in subsection 4 of the Warrant.
Dated:_______________________________
Signature:____________________________
Witness:_____________________________
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