Box 1.
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☐
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Please DO NOT EXERCISE RIGHTS for Common Shares.
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Box 2.
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☐ |
Please EXERCISE RIGHTS for Common Shares as set forth below:
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Number of Common Shares Subscribed For
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Subscription Price per Common Share
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Payment
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Basic Subscription Right
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x
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$1.00
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=
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$_____________
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Oversubscription Right
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x
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$1.00
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=
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$_____________
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Total Payment Required
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$_____________
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Box 3.
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☐ |
Payment in the following amount is enclosed: $____________
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Box 4.
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☐ |
Please deduct payment of $________ from the following account maintained by you as follows:
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Type of Account: _________________________________
Account No.: _________________________________
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· |
irrevocably elect to purchase the number of Common Shares indicated above upon the terms and conditions specified in the Prospectus Supplement; and
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· |
agree that if I (we) fail to pay for the Common Shares I (we) have elected to purchase, you may exercise any remedies available to you under law.
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Name of beneficial owner(s):
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Signature of beneficial owner(s):
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If you are signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or another acting in a fiduciary or representative capacity, please provide the following information:
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Name:
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Capacity:
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Address (including Zip Code):
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Telephone Number:
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