|
|
|
|
||
John North, Chief Executive Officer
|
Kelly Porter, Chief Financial Officer
|
If delivering by hand or overnight courier:
|
|
If delivering by first class mail:
|
|
|
|
Broadridge Corporate Issuer Solutions, LLC
|
|
Broadridge Corporate Issuer Solutions, LLC
|
Attn: BCIS IWS
|
Attn: BCIS Re-Organization Dept.
|
|
51 Mercedes Way
|
P.O. Box 1317
|
|
Edgewood, NY 11717
|
Brentwood, NY 11717-0718
|
(a)
|
EXERCISE OF SUBSCRIPTION RIGHT:
|
(i)
|
Basic Subscription Right
|
I exercise
|
x
|
0.770
|
=
|
x
|
$6.399
|
$
|
||
(No. of shares owned)
|
x
|
(Initial ratio)
|
=
|
(No. of Basic Subscription Shares Subscribed For)
|
x
|
(Initial Price)
|
(Amount Enclosed)
|
(ii)
|
Over-Subscription Right: If you fully exercise your Basic Subscription Right, above, and wish to subscribe for additional shares, you may exercise your
Over-Subscription Right below.
|
I exercise |
|
x
|
$6.399
|
=
|
$
|
(No. of Over-Subscription Shares Subscribed For)
|
x
|
(Initial Price)
|
=
|
(Amount Enclosed)
|
(b)
|
PAYMENT:
|
Amount Enclosed
|
||||
Basic Subscription Right:
|
$
|
|
☐ Certified check drawn on a U.S. bank, or postal or express money order payable to Broadridge Corporate Issuer Solutions, LLC, as Subscription Agent. |
|
Over-Subscription Right:
|
$
|
|
☐ Wire transfer directly to the escrow account maintained by Broadridge Corporate Issuer Solutions, LLC, as Subscription Agent. |
|
Total Amount Enclosed
|
$
|
(c)
|
SIGNATURE(S):
|
|
|||
Signature(s) of Subscriber(s)
|
Date
|
Daytime Telephone Number(s) |
Name(s)
|
Full Title
|
Taxpayer ID # or Social Security #
|
Date
|
(a) To be completed ONLY if the book-entry representing the Common Stock is to be issued in a name other
than that of the registered holder. (See the Instructions.) DO NOT FORGET TO COMPLETE THE GUARANTEE OF SIGNATURE(S) SECTION BELOW.
|
(b) To be completed ONLY if the book-entry representing the Common Stock is to be issued to an address
other than that shown on the front of this certificate. (See the Instructions.) DO NOT FORGET TO COMPLETE THE GUARANTEE OF SIGNATURE(S) SECTION BELOW.
|
Print Full Name:
|
Print Full Name:
|
||
Print Full Address:
|
Print Full Address:
|
||
Taxpayer ID # or Social Security #:
|
Taxpayer ID # or Social Security #:
|
Signature Guaranteed:
|
|
|
|
|
|
|
|
(Name of Bank or Form)
|
|
|
|
|
|
|
By:
|
(Signature of Officer)
|