TPTX » Topics » (To be executed if holder desires to exercise the Rights Certificate other than pursuant to Section 11(a)(ii) of the Rights Agreement.)

This excerpt taken from the TPTX 8-K filed May 16, 2005.

(To be executed if holder desires to exercise
the Rights Certificate other than pursuant to
Section 11(a)(ii) of the Rights Agreement.)

To AXONYX INC.:

The undersigned hereby irrevocably elects to exercise ______________ Rights represented by this Rights Certificate to purchase the shares of Preferred Stock (or such other securities of the Company or any other Person) issuable upon the exercise of the Rights and requests that certificates for such shares be issued in the name of:

 
__________________________________________________________________________
(Please insert social security or other identifying number)
 
__________________________________________________________________________
(Please print name and address)
 
The Rights Certificate indicating the balance, if any, of such Rights which may still be exercised pursuant to Section 11(a)(ii) of the Rights Agreement shall be returned to the undersigned unless such Person requests that the Rights Certificate be registered in the name of and delivered to: (Complete only if Rights Certificate is to be registered in a name other than the undersigned.)
 
__________________________________________________________________________
Please insert social security or other identifying number
 
__________________________________________________________________________
(Please print name and address)
   
   
Dated:______________, 20__.  
   
   
________________________ ________________________
Signature Signature
   
Signature(s) Guaranteed:  
   
________________________  

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